Pediatric Urology - Information and Specialized Pediatric Urologists

The field of pediatric urology deals with the diagnosis, treatment, and management of

• diseases,
• injuries,
• functional disorders, and
• congenital malformations

of the urogenital tract. The urogenital tract includes

• the urethra,
• the bladder,
• ureters, and
• renal pelvis, as well as
• the external and internal reproductive organs.

The most common conditions treated by pediatric urologists in children are phimosis (a narrowing of the foreskin) and problems with bladder control (micturition disorders).

Congenital malformations of the urethra or ureters are also among the most commonly treated conditions. Today, such malformations can often be detected as early as during routine ultrasound examinations in pregnancy.

In addition, pediatric urology deals with numerous other, mostly rarer urological conditions and malformations, as well as injuries to the urinary tract and the internal and external genitalia. Injuries are most often caused by traffic accidents, sports, and recreational activities.

The following list provides a general overview of the scope of services provided by a pediatric urologist. In the area of the urinary tract, this includes, for example, the diagnosis and treatment of the following conditions:

• Enuresis (persistent bedwetting at night and/or during the day)
• Severe or chronic urinary tract infections
• Urinary flow and bladder emptying disorders
• Urinary tract stone disease (urinary stones)
• Rare bladder malformations, such as bladder exstrophy (a bladder that is open to the outside)
• Tumors of the urogenital system, such as Wilms’ tumor (a rare kidney tumor that occurs in early childhood)
• Kidney diseases, such as hydronephrosis (swollen kidney)

Disorders of urinary transport and bladder emptying include, for example

• dilatations or narrowings (stenoses) of the urethra and ureters (such as megaureter, ureteropelvic junction obstruction),
• urethral valve disease,
• a downward displacement of the urethral opening (hypospadias) or an upward displacement (epispadias),
• vesicoureteral reflux (backflow of urine into the ureters and/or urine as well as
• a neurogenic bladder

In the genital area, this includes, for example, the diagnosis and treatment

• of phimosis
• cryptorchidism (undescended testicles) and inguinal hernias
• hydrocele (accumulation of fluid in the scrotum) and varicocele (varicose veins of the testicle)
• acute scrotal pain
• fused labia (labial synechia)
• Conditions affecting the external genitalia
• Ambiguities of physical sex (so-called Disorders of Sex Development (DSD), formerly known as intersex)

Due to the child’s young age, the doctor usually conducts the medical history interview with the parents. The doctor asks about symptoms, such as pain, fever, or discomfort during urination.

This is followed by a thorough physical examination. The pediatric urologist will conduct the examination gently and in a trusting manner, taking any feelings of embarrassment into account. If necessary, young children may be held in their parents’ arms or on their parents’ laps during the examination.

The physical examination includes

• palpation of the abdomen,
• an examination of the genital area, and
• measuring heart rate and blood pressure.

As part of laboratory diagnostics, urine is occasionally tested—especially when a urinary tract infection is suspected—and blood is analyzed.

Ultrasound as the Most Important Diagnostic Tool

Using imaging techniques, the pediatric urologist can assess urological diseases and malformations.

Ultrasound (sonography) is the primary method here, as it allows for the straightforward examination of internal organs and the urinary tract. Ultrasound does not expose patients to radiation. State-of-the-art technology is used, such as

• high-resolution ultrasound,
• color-coded duplex sonography (to determine the direction of blood flow), or
• three-dimensional sonography

This allows us to detect not only anatomical changes but also functional disorders. The majority of pediatric urological conditions can be diagnosed with an ultrasound examination.

Other imaging techniques

Unlike adults, children are ten times more sensitive to radiation. This also means they face a significantly higher risk of developing what is known as a radiation-induced tumor. For this reason, computed tomography (CT), which involves high radiation exposure, plays only a minor role in pediatric urology.

In contrast, magnetic resonance urography (MRU), a specialized form of magnetic resonance imaging (MRI), has established itself as a radiation-free method. Using a strong magnetic field, high-resolution cross-sectional images are generated, which can be used to assess both the anatomy of the entire urogenital tract and kidney function.

Despite a certain level of radiation exposure, voiding cystourethrography (MCU) remains one of the most important examinations in pediatric urology due to its high diagnostic value regarding anatomy and function.

In this examination, the bladder is filled with contrast medium either via a bladder catheter inserted through the urethra or by puncturing the bladder through the skin, after which X-ray images are taken.

In addition, there are other imaging techniques that can be used for specific diagnostic purposes, such as

• pyelography (imaging of specific areas of the renal pelvis),
• laparoscopy (abdominal endoscopy), or 
• scintigraphic methods (use of radioactively labeled substances to assess kidney function).

Cystoscopy

Another relatively common urological examination is cystoscopy. Using a tiny video scope inserted through the urethra, the pediatric urologist can examine the inside of the urethra and bladder. As part of bladder pressure measurement (urodynamics), pressure probes and electrodes are used to assess bladder function.

Examinations that are perceived as uncomfortable, or those that require young patients to lie still for a relatively long time, are usually performed under brief anesthesia.

Pediatric urologists often resort to conservative treatments, which involve the use of medications administered either internally or externally. 

Surgical procedures are also frequently used in pediatric urology to treat diseases or congenital anomalies. The range of procedures spans from routine to highly delicate or highly specialized surgical interventions.

• Phimosis,
• undescended testicles,
• obstructions of urine flow, and
• other congenital malformations requiring correction

are usually treated surgically during the first few years of life. The pediatric urologist routinely performs many of these procedures using minimally invasive techniques (so-called keyhole surgery) via laparoscopy or cystoscopy. This results in no visible scars or only very small ones.

Most urological conditions and malformations that occur in childhood can be treated with routine procedures or well-established conservative therapies. Often, phimosis, urinary tract obstruction, and other disorders even resolve on their own without any treatment. However, only a pediatric urologist can determine whether a “wait-and-see” approach is a sensible strategy.

Children with rare and more complex disorders of the urogenital tract are best cared for at pediatric urology centers in major hospitals.

The specialists working there collaborate closely, as needed, with

• pediatric nephrologists (for kidney problems),
• pediatric neurologists (for example, for neurologically caused bladder dysfunction),
• pediatric oncologists (for cancer) and
• pediatric endocrinologists (for example, in cases of disorders of sex development (DSD))

.

A pediatric urologist has completed specialty training in pediatric surgery or urology. They have typically also completed additional specialized training. At the European level, there is an official designation for this specialized training (Fellow of the European Academy of Pediatric Urology (FEAPU)).

In Germany, specialized pediatric urologists work at pediatric urology centers in major hospitals. In addition, many urology practices offer pediatric urology consultation hours. Private-practice pediatric surgeons also occasionally perform surgeries on the urogenital tract.