Voiding dysfunction is a common problem in childhood and causes concern for parents. Symptoms of this disorder are frequent voiding, urgency to void, and wetness. These symptoms are typical in young children with immature bladders. Development of a mature bladder requires increased bladder capacity, voluntary control of the sphincter muscle, and control of involuntary bladder contractions. Most children achieve adult pattern bladder control by age four. However, almost every child will exhibit some symptoms of voiding dysfunction during the transition from infant to adult patterns of bladder control. Initial examination includes a history and physical examination as well as urinalysis. Timed voiding and anticholinergic medications are effective treatment options for children with urgency, frequency, and urge incontinence. In some cases, a special test of bladder function may be indicated. Children with significant behavioral problems may benefit from behavioral counseling. Children with developmental delays due to persistently immature bladders will often exhibit delays in toilet training.

Meatal stenosis refers to an abnormal narrowing of the opening of the urethra, which can lead to difficulty urinating and incomplete emptying of the bladder. The condition commonly affects circumcised boys, and one possible cause is prolonged exposure to urine and rubbing of the flesh against clothing or diapers, resulting in irritation and scarring.

Common symptoms of meatal stenosis include painful urination, straining during urination, frequent urination, thin urine stream, sprinkling with urine, upward turning of the urine stream, and blood in the urine.

Treatment of meatal stenosis involves mitoplasty or mitotomy. Mitoplasty involves opening or widening the meatus by making an incision at the urethral opening and placing a vascularized flap, typically from the prepuce or surrounding penile skin, to prevent recurrence of the stricture. Mitotomy, on the other hand, involves making a small incision in the flesh to widen it, and the cut margin is either sutured with dissolvable sutures or left alone to heal. The surgeon will discuss with you the best treatment plan for your child. Some children may need to open the urethra after these procedures to prevent recurrence of the stricture.

One of the primary reasons for bladder enlargement or replacement surgery is in certain conditions such as spina bifida, posterior urethral valve or bladder exstrophy, where the bladder becomes smaller and holds urine under high pressure. Such an abnormal bladder can cause incontinence and kidney damage. In these cases, the bladder needs to be enlarged to relieve symptoms and protect the kidneys. For patients with cancer of the bladder or other pelvic organs, it becomes necessary to remove the bladder, and usually to replace the bladder, a new reservoir must be created, along with a path for urine to drain through the normal passage or a new stoma.

However, this operation can lead to complications. For example, the bowel does not function like a normal bladder, so patients require intermittent catheterization to empty their bladder. Additionally, the bowel produces mucus that blocks the catheter draining the bladder immediately after surgery. This fluid needs to be removed from the bladder daily to prevent the development of bladder stones or infections. Patients are also at risk of bowel complications such as leakage of bowel contents, bowel obstruction, and bladder rupture or perforation. The risk of bladder rupture is higher in patients who fail to undergo regular catheterization, leading to chronic over-distension of the bladder and weakening of the bladder walls due to ischemia. Finally, patients on intermittent catheterization for neurogenic bladder and those who have undergone bladder augmentation are at increased risk of bladder cancer.

Constipation is a condition that can be diagnosed using the Rome IV criteria, which states that a patient must have experienced at least two of the following symptoms over the preceding 3 months: fewer than three spontaneous bowel movements per week, straining for more than 25% of defecation attempts, lumpy or hard stools for at least 25% of defecation attempts, sensation of anorectal obstruction or blockage for at least 25% of defecation attempts, sensation of incomplete defecation for at least 25% of defecation attempts, or manual maneuvering required to defecate for at least 25% of defecation attempts. Constipation is common in children with urinary tract infections, daytime wetting, and night-time wetting, but it is not a life-threatening condition.

Treatment of constipation involves education, prevention of impaction, promotion of regular bowel habits, and toilet training in older children. Daily bowel movements are essential in treating constipation, and a soft bowel movement should be the goal for the child every day. This can be achieved by providing a daily stool time, ideally 15 to 20 minutes after eating to take advantage of the gastrocolic reflex. It is important not to rush and to allow the child plenty of time in the bathroom, usually 5-10 minutes. Keeping a stool diary can also be helpful to monitor consistency.

There are several dietary measures that can improve constipation, including increasing fluid intake, adding fruit juices such as prune, pear, plum, pineapple, peach, papaya, apricot, orange, or apple, vegetables (either raw or cooked), fruits (including peels as often as possible), bran cereal, bran muffins, raisin bran, and bananas. It is important to avoid certain foods that may worsen constipation, including dairy products (milk, cheese, ice cream), rice or rice cereal, pastas, white bread, and potatoes.

In some cases, supplements may be prescribed to produce daily bowel movements, such as magnesium citrate, Miralax, mineral oil, or Milk of Magnesia. Dosages will be determined by a physician.

Management of constipation requires patience and effort on both the child’s and the parent’s part, and multiple clinic visits may be necessary until appropriate laxative dosage has been established. It is important to keep in mind that dietary factors alone may not alleviate chronic constipation if stool withholding and retention are a problem. In some children with neurological conditions affecting the bowel and bladder, regular enemas may also be required.

A kidney stone is a solid mass that develops in the kidney due to the crystallization of certain substances in previously dissolved urine. Usually, the stone stays in the kidney or passes through the urinary tract when dislodged.

Kidney stones can vary in shape and size from a grain of sand to the size of a golf ball. While some stones are smooth, others are jagged and staghorn stones can even fill the entire kidney. Although not all kidney stones are symptomatic, a small stone can pass through the body without causing significant discomfort. However, if stones remain in the bladder, urethra, or urethra, they can block the flow of urine and result in pain and obstruction.

Kidney stones can develop as a result of dehydration, metabolic diseases, infections, medications, limited activity, diet, family history, and conditions that increase the concentration of certain substances in the urine, such as calcium, oxalate, and uric acid. Calcium is the most common type of stone.

Symptoms of kidney stones include severe pain in the back or side that radiates to the inguinal region and usually include cramping, blood in the urine, vomiting, fever, chills, urinary urgency or frequency, and pain or burning while urinating.

Treatment of kidney stones depends on the type, size and location of the stone. Conservative measures may be sufficient for some stones, but others may require surgery, such as extracorporeal shock wave lithotripsy, endoscopy, percutaneous nephrolithotomy, or rarely, pyelolithotomy. To prevent the formation of stones in the future it is necessary to determine the root cause of kidney stones and for this purpose blood and urine tests can be done. Prevention of kidney stones is usually accomplished through water intake, dietary changes, and, if necessary, medications. During your office visit, your doctor will determine the appropriate treatment for your child’s kidney stones.

Multicystic dysplastic kidney (MCDK) is a type of congenital kidney abnormality where the kidney is completely replaced by multiple cysts held together by connective tissue like a bunch of grapes. The ureter is often atretic or absent, and the cysts usually do not communicate, distinguishing MCDK from hydronephrosis. Nowadays, 47% of cases occur prenatally, while 30% of cases present with a lateral mass, 5% with urinary tract infection, and 18% with other symptoms. Males are more commonly affected, and there is a slight left-sided predominance.

To diagnose MCDK, a renal ultrasound is usually performed, which shows characteristic features that distinguish it from hydronephrotic kidneys. A renal scan such as DMSA or MAG-3 is usually obtained to confirm the diagnosis and evaluate the contralateral kidney. In some cases, a nuclear cystogram or voiding cystourethrogram is also recommended to evaluate for contralateral vesicoureteral reflux. If MCDK is detected prenatally, it is important to assess the amount of anti-kidney and amniotic fluid. In rare cases, surgical exploration is required if the diagnosis is inconclusive despite radiological workup.

Treatment for MCDK is controversial. While some advocate surgical removal of the affected kidney, others prefer observation. Leaving the kidney in place carries a risk of hypertension (rare) and renal tumors, but the risk is low with only six reported cases. If the kidney is left in place, patients should have an annual renal ultrasound and blood pressure measurement. In general, MCDK patients do well with one kidney because bilateral disease is rare.

Bed-wetting during sleep is the most common urological issue observed in children. Also known as Sleep Enuresis or Nocturnal Enuresis, it affects about 10-20% of children aged 5-6 years. It is estimated that 80-110 million children worldwide have enuresis, which is more common in first-born children and boys than girls. There is also a higher chance of a child having enuresis if the parents had a similar problem or a family history of the condition. Enuresis is only considered a disorder if it continues for approximately one year, and the child is at least 5 years old. It is primary enuresis if it has been present since birth and secondary enuresis if it starts between the ages of 5-8 years.

Bed-wetting can affect a child’s self-esteem, and treatment is recommended. Monosymptomatic nocturnal enuresis (MNE) is when a child wets the bed only at night and has no other urological issues. MNE must be distinguished from children who have both night-time incontinence and daytime symptoms such as urgency, frequency or incontinence. Approximately 25% of children who attain initial night-time dryness by the age of 12 years, relapse and wet for a period averaging 2.5 years. The spontaneous resolution rate for nocturnal enuresis is 15% per year, and by the age of 15, it persists in only 1% of the population.

MNE is a symptom rather than a disease, and there is no single explanation for this symptom. A variety of factors such as behavioural, genetic, developmental, neurologic, psychological, urodynamic and organic causes have been proposed. Investigations and treatments along these lines are both inappropriate and unrewarding because most children with MNE do not have psychiatric, neurologic or urological disturbances.

A variety of treatment modalities have been used to treat nocturnal enuresis. However, their effectiveness, even in control studies, has been difficult to assess because of the high spontaneous resolution rate and the extremely high placebo improvement effect. Therapy generally follows two lines – drug therapy and behavioural modification. Parents have different attitudes and expectations about bed-wetting and its cure.

Children born with spina bifida commonly have urinary tract abnormalities. The urinary tract includes the kidneys, ureters, bladder, and urethra. Kidneys filter waste from the blood and produce urine. Ureters transport urine to the bladder, which stores urine until it is excreted through the urethra. Proper bladder function requires an intact sacral spinal cord. Children with spina bifida often have damaged nerves to the bladder, which can lead to urinary incontinence and poor control. Such dysfunctions can also result in kidney and bladder damage. To evaluate the urinary tract, ultrasounds of the kidneys and x-rays of the bladder are performed to assess bladder capacity and urethra, and detect any congenital abnormalities of the kidneys. Urodynamic studies of the bladder are essential for children with spina bifida, to identify the likelihood of renal damage. Treatment depends on the degree of bladder pressure: children with lower bladder pressures (less than 35 cm H2O) may only need to be monitored. Those with high bladder pressures may require intermittent catheterization, where the bladder is emptied with a clean tube every four hours, or medication to lower bladder pressure. Regular monitoring and repeated urodynamic studies are necessary to identify any loss of bladder function. Urinary tract infections are common in children with spina bifida, especially those with high bladder pressures, and frequent emptying of the bladder is essential to prevent them. Surgical intervention may be necessary in cases of high bladder pressure.

It is not uncommon for children with urinary issues to withhold their urine for extended periods. However, it can be challenging for parents to identify this behavior since they are usually unaware of when their child has gone to the bathroom. Holding in urine can result in bacterial overgrowth or an overfilled bladder, which may cause urine to leak out.

Encouraging a child to urinate is difficult if they are not willing to do so. Emotional pressure or fear of punishment can hinder a child’s ability to relax enough to effectively empty their bladder. Normal urination requires the coordination of the pelvic floor muscles and bladder muscles. While the pelvic floor muscles can be voluntarily controlled, the bladder muscles are automatic and cannot be consciously controlled. Straining or pushing to urinate is not recommended; relaxation is essential.

Girls should sit back on the toilet with foot support if necessary, relax, and avoid straining or pushing their knees apart. They should take their time and try to urinate again once they finish since there may be more urine left in the bladder. Boys should completely open their pants zip, relax, and avoid straining or rushing. They should sit if it helps, and once they finish, wait a moment and try again.

A timed voiding program can be helpful in relearning to empty the bladder when it is time to do so rather than waiting until it is too late. This involves scheduling times to urinate throughout the day, which helps to keep the bladder empty and reduces the risk of urine leakage or infection. An alarm watch or phone alarm can be useful reminders at home or playtime, whereas a set schedule during school hours is more appropriate. The voiding habits mentioned above are crucial to ensure that the bladder is fully emptied without straining.

Some people may believe that they cannot or do not need to urinate. However, this is unlikely since everyone continuously produces urine. Therefore, learning to relax when it is time to urinate is crucial.

The male hormone and sperm are produced by the testicle. An undescended testicle occurs when the testicle cannot be found in its normal position in the scrotum. The testis normally migrates down from high in the abdomen and groin to take its normal position in the scrotum before a child is born. Up to 4% of term infants have an undescended testicle, with a higher incidence in premature males. Spontaneous descent into the scrotum occurs in three-fourths of undescended testicles during the first three months of life.

Most undescended testicles are palpable in the groin, but some are nonpalpable, being intra-abdominal or absent. Retractile testicles are not truly undescended but withdraw into a position outside of the scrotum because of a hyperactive cremasteric reflex. Retractile testicles can be manipulated into the scrotum, but some go on to become undescended as the child grows.

Treatment for the undescended testicle can be undertaken any time after 6-9 months of age. Relocating the testis into the scrotum may decrease the risk of fertility problems, particularly if done at an early age. There are other advantages to a location within the scrotum, including a cosmetic advantage and alleviation of any psychological effects resulting from an empty scrotum. The scrotal testis may be less amenable to injury than a testis outside the scrotum.

A testis that has not made it into the scrotum is not accessible to physical examination and is at increased risk for testicular cancer, the most common solid tumour in men up to age 40 years. Testicular carcinoma is highly curable when detected early, and monthly self-examination is the best way to do this. Treatment for an undescended testicle may involve hormonal therapy, although the success rate is below 10% when retractile testicles are excluded from the treatment groups. The surgical treatment for an undescended testicle is called an orchiopexy. Palpable undescended testicles are found through a small inguinal skin incision. Nonpalpable undescended testicles require surgical exploration, and this is done by diagnostic laparoscopy. Most of these children probably had torsion or twisting of the testis on its blood supply prior to birth that led to the small testis. When a boy is left with a single functioning testis, we may recommend anchoring it to minimize the chances of losing it to torsion later in life.

Urotherapy counselling is a non-invasive therapy used to manage dysfunctional voiding and irregular bowel movement habits. Dysfunctional voiding occurs when the urethral sphincter does not relax during urination, causing difficulty in expelling urine. This leads to increased bladder pressure and changes in the urinary bladder’s micro-organic climate, which can result in a urinary tract infection. Irregular bowel movements can cause impacted stool in the rectum, which compresses the bladder, reduces its functional capacity, and leads to earlier sensations to void. Urotherapy aims to normalize bladder and bowel function, ultimately improving quality of life.

Urotherapy involves maintaining safe bladder storage volumes and regular bowel movements to prevent pressure on the urinary bladder and facilitate pelvic muscle relaxation. Medications like anticholinergics and laxatives may also be used, if necessary. A doctor or trained nurse counsellor will assess your clinical condition and provide tailored recommendations. These recommendations may include tailoring fluid consumption, restricting fluid consumption in the evenings, timed urination, passing urine before bed and immediately upon waking, passing urine once at night, maintaining a two-hour interval between dinner and sleep, increasing fibre in the diet, and passing stools daily at fixed times.

After a month, you will be asked to return with a bladder diary to evaluate your compliance with the advice. The bladder diary records information such as time of waking and sleeping, fluid intake, frequency and volume of urination, degree of urgency, and episodes of leakage. The nurse counsellor will provide guidance on maintaining a bladder diary.

Varicocele is a medical condition characterized by an abnormal enlargement or dilation of the veins within the spermatic cord, which carry blood away from the testicle. This condition is often painless but can cause discomfort, heaviness, or a “dragging feeling” in the scrotum. When examined, the veins above the testicle feel like a “bag of worms.” The varicocele becomes smaller when the patient lies down and larger when standing up.

While varicocele is uncommon in children under 10 years of age, it becomes more prevalent after puberty and affects 16% of adolescent boys, usually on the left side. The exact cause of varicocele is unknown.

Varicoceles have been linked to infertility, with 20-40% of infertile men found to have a varicocele and low sperm counts. However, most men with varicoceles have normal sperm counts and are fertile. The increased temperature caused by the enlarged veins in the testicle is believed to impair sperm production.

Although it is currently impossible to accurately predict which boys with varicoceles will experience fertility issues later in life, if the testicle on the side of the varicocele is smaller or not growing normally compared to the other side, this is considered a sign of ongoing damage and requires varicocele repair. Additionally, if the varicocele is large and causing pain, it should also be corrected. If there are no symptoms and both testicles are normal in size and growth, no treatment is necessary.

Microsurgical subinguinal approach is one of the most effective and least invasive methods of treating varicocele. This involves making a small incision at the root of the scrotum and using an operating microscope to identify and ligate the affected veins on one or both sides.

This brochure aims to provide information about Vesicoureteral Reflux (VUR) and the various treatment options available. VUR occurs when urine flows back from the bladder to the kidney through the ureters, instead of flowing down into the bladder. Primary reflux is caused by an intrinsic defect in the valve mechanism at the junction of the ureter and bladder, while secondary reflux is due to other causes in the bladder and outflow urinary tract. VUR can lead to urinary infections, renal scarring, hypertension, and even renal failure. Therefore, it is important to detect and treat VUR promptly to protect the kidneys from damage.

Tests used to evaluate VUR include ultrasound studies, voiding cystourethrogram (VCUG), and isotope study (DMSA) of the kidneys. Any child with urinary tract infection should be evaluated, and the choice of tests will depend on the child’s age, symptoms, and the ultrasound report. Symptoms of urinary tract infections include foul-smelling or turbid urine, fever, abdominal pain, burning or pain when urinating, frequent and urgent urination, and urine infection.

There are three options for managing or treating VUR, including antibiotics, surgery, and endoscopic treatment. Antibiotics may be used to prevent infections until low-grade VUR resolves itself as the child grows. Surgery can fix the ureters to stop high-grade VUR, and this treatment cures most children. Endoscopic treatment involves injecting a substance where the ureter joins the bladder in low-grade VUR. The choice of treatment should be discussed in detail with the doctor, taking into account the child’s medical history and the family’s personal views. It is important to understand the risks, benefits, and follow-up of each treatment.