Imaging in pediatric urology

The prevalence of kidney scarring due to urinary tract infection in Iranian children: a systematic review and meta-analysis

INTRODUCTION

Urinary tract infection is one of the most common diseases in childhood, and can lead to severe complications such as renal scarring in case of lack of diagnosis and timely treatment.

OBJECTIVE

The aim of this study was to investigate the prevalence of kidney scarring caused by urinary tract infection in Iranian children by meta-analysis.

STUDY DESIGN

English -language databases including Science Direct, PubMed, Scopus, Web of Science, and Springer, and Persian -language sites including SID, Magiran, Iranmedex, and Medlib, and the Google Scholar search engine were searched by in March 2018 using MeSH keywords. The heterogeneity of studies was studied using the I2 index. Data were analyzed using STATA software, version 15.1.

RESULTS

In 18 studies, the prevalence of kidney scarring from urinary tract infections in Iranian children was 31% (95% confidence intervalCI: 22%-39%), (which was 14% in girls and 23% in boys. Also, the prevalence of kidney scar in children with urinary reflux was 47% and in children without urinary reflux was 12%. The most common symptom of the renal scar was fever in 61%, followed by urinary reflux in 45% (unilateral in 42% and bilateral in 30%). Also, the prevalence of mild, moderate, and severe reflux, respectively, was 31%, 27%, and 13%. Meta-regression also showed that the prevalence of kidney scar due to urinary tract infections had no significant relationship with the number of samples and years of research (P > 0.05).

DISCUSSION AND CONCLUSION

About one-third of Iranian children suffering from urinary tract infections had kidney scarring, so that the prevalence is lower in girls than in boys. Also, the prevalence of renal scarring in children with urinary reflux is about four times higher than that in children without urinary reflux.

Accuracy of early DMSA scan for VUR in young children with febrile UTI

OBJECTIVE

To evaluate the accuracy of an acute (99m)Tc-dimercaptosuccinic acid (DMSA) scan in predicting dilating vesicoureteral reflux (VUR) among young children with a febrile urinary tract infection (UTI).

METHODS

The medical records of children (≤ 2 years of age), presenting with febrile UTI between January 2000 and December 2011, were retrospectively reviewed.

RESULTS

A total of 523 children were included in this study, of whom 397 children (75.9%) had abnormal DMSA results and 178 children (34.0%) were identified as VUR on micturating cystourethrography (MCU). Among all the patients, the number of children with dilating VUR was 151 (28.9%). The rate of abnormal results on DMSA for the dilating VUR group was significantly higher than the rates for the non-VUR and low-grade VUR groups (P < .01). In the <6 months age group and ≥ 6 months age group, the sensitivities of DMSA in predicting dilating VUR were 96.15% and 100.0%, respectively, the negative predictive values were 97.26% and 100.0%, respectively, and the negative likelihood ratios were 0.0911 and 0.0000, respectively.

CONCLUSION

For children ≤ 2 years of age with a febrile UTI, an acute DMSA scan is valuable in the exclusion of dilating VUR. The likelihood of the presence of dilating VUR on MCU is rather low when the result of DMSA is negative. DMSA should be conducted to assess the need for an MCU.

Acute idiopathic scrotal edema

We report a case of acute idiopathic scrotal edema (AISE) in a 4-year-old boy who presented with acute scrotal pain and erythema. The clinical features, ultrasound appearance, and natural history of this rare diagnosis are reviewed. In this report, we highlight the importance of good ultrasound technique in differentiating the etiology of the acute scrotum and demonstrate the color Doppler “Fountain Sign” that is highly suggestive of AISE.

The bear paw: a radiologic sign for congenital ureteropelvic junction obstruction

This article defines a new radiographic descriptor of high-grade hydronephrosis suggestive of ureteropelvic junction obstruction that is easily recognized by urologists and non-urologists alike. This is useful information for medical personnel participating in the management of children with hydronephrosis.

[Imaging in the management of urinary tract infections]

This review analyzes the role of imaging in the diagnosis, follow-up and management of urinary tract infections. Uncomplicated infection of the urinary tract is frequent and usually resolves rapidly with treatment; in such cases imaging is unnecessary except to exclude dilatation or the existence of an obstacle. Progression towards complex infection often occurs in patients with predisposing factors. Imaging helps in evaluating the extent of the disease; it has a role in the selection of therapy and interventional procedures.

Evaluation of hematuria in children

The detection of blood in a child's urine is alarming and often prompts many laboratory studies. Hematuria is one of the most important signs of renal or bladder disease, but proteinuria often is a more important diagnostic and prognostic finding. The physician should ensure that serious conditions are not overlooked, avoid unnecessary laboratory studies, reassure the family, and provide guidelines for additional studies if there is a change in the child's course. This article provides an approach to the evaluation and management of hematuria in a child. Many tests have been recommended for the child with hematuria, but no consensus exists on a systematic evaluation.

Conventional imaging in paediatric uroradiology

OBJECTIVE

To briefly describe basic conventional imaging in paediatric uroradiology.

METHOD

The state of the art performance of standard imaging techniques (intravenous urography (IVU), voiding cystourethrography (VCU), and ultrasound (US)) is described, with emphasis on technical aspects, indications, and patient preparation such as adequate hydration. Only basic applications as used in routine clinical work are included.

RESULT AND CONCLUSION

Conventional imaging methods are irreplaceable. They cover the majority of daily clinical routine queries, with consecutive indication of more sophisticated modalities in those patients who need additional imaging for establishing the final diagnosis or outlining therapeutic options.

Hematuria in children

Children with hematuria require a thorough history and physical examination. Not all children with hematuria require the same investigations. The only laboratory test uniformly required for children with the various presentations of hematuria is a complete urinalysis with a microscopic examination. The rest of the evaluation is tailored according to the pertinent history, physical examination, and other abnormalities on the urinalysis. This article has provided a brief summary of the more common causes of pediatric hematuria and suggestions for tailoring the patient's evaluation according to the presentation. Most causes of hematuria in pediatrics represent medical conditions that often require referral to a pediatric nephrologist. Indications for referral to a urologist are more limited and include stones that do not pass spontaneously or are more than 5 mm in diameter, renal injury from trauma, anatomic abnormalities, or gross hematuria that seems to originate from the urinary tract and is without an identified cause.

Genitourinary imaging in children

Genitourinary imaging in children has gone through a metamorphosis in the past 30 years, paralleling technical advances in sonography, CT scanning, and MR imaging. The imaging sequences for hydronephrosis and UTI are still controversial and require outcomes analysis to determine which studies are most beneficial and efficacious.

Genitourinary trauma

Injuries to the GU system commonly occur in patients with high-energy lower abdominal or pelvic trauma. The emergency physician should be well versed in the diagnosis and management of GU trauma, although these injuries are not usually life threatening because of the potential for loss of urinary or sexual function. In the setting of hemodynamic instability, diagnosis and treatment of GU injuries is often accomplished in the operative setting. In the stable patient, diagnostic testing is directed by the type of suspected injury and must proceed in a reverse manner, i.e., external injury then urethral injury then bladder, and finally urethral and renal damage. Treatment focuses on a team approach between the emergency physician, general, orthopedic, and urologic surgeon. The decision for operative repair is often dictated more by other associated injuries than urologic injuries, and the urologic surgeon often provides temporizing measures with definitive repair at a later time. Prompt diagnosis and treatment of injuries to the external genitals results in excellent long-term outcome, minimizing the devastating consequences of impotence, urinary incontinence, and sexual disfiguration.

Pediatric urinary tract infection

UTIs are common in children. They may present with a range of severity from cystitis to febrile UTI or pyelonephritis. The presentation may be vague and have nonspecific symptoms. Therefore, a UTI should be considered in all children with a fever in whom other sources have been excluded. Treatment depends on the age, location of infection, and degree of illness in the child. Sick children and infants less than 3 months should be treated as inpatients, and healthy children and older infants may be treated as outpatients. Urinalysis provides presumptive evidence of infection, whereas urine culture is definitive. Close follow-up and outpatient evaluations are needed to prevent long-term consequences of infection.

Diagnostic procedures for the urogenital system

In making clinical decisions concerning the urogenital system, the emergency department physician has many different diagnostic tools at his or her disposal. Choosing the appropriate diagnostic study can often be difficult. For well over a thousand years, the initial step in assessing almost any urologic condition has been to examine the urine. Thankfully, this has progressed from a gustatory approach to the modern urinalysis. There is certainly a great deal of information that may be gleaned from the urinalysis, but the physician must also be mindful of its limitations. Overuse of the urinalysis can result in unwanted and unhelpful information. Although IVP is still the study of choice in assessing the functional status of the kidney, the introduction of CT and ultrasound technology to clinical medicine has revolutionized the emergency department assessment of the urogenital tract. CT and ultrasound can help differentiate between the urologic emergencies and the various surgical conditions that can mimic them.

Abdominal trauma in infants and children: prompt identification and early management of serious and life-threatening injuries. Part II: Specific injuries and ED management

Evaluation of children with suspected abdominal trauma could be a difficult task. Unique anatomic and physiologic features render vital sign assessment and the physical examination less useful than in the adult population. Awareness of injury patterns and associations will improve the early diagnosis of abdominal trauma. Clinicians must have a complete understanding of common and atypical presentations of children with significant abdominal injuries. Knowledge of the utility and limitations of available laboratory and radiologic adjuncts will assist in accurately identifying abdominal injury. While other obvious injuries (eg, facial, cranial, and extremity trauma) can distract physicians from less obvious abdominal trauma, an algorithmic approach to evaluating and managing children with multisystem trauma will improve overall care and help to identify and treat abdominal injuries in a timely fashion. Finally, physicians must be aware of the capabilities of their own facility to handle pediatric trauma. Protocols must be in place for expediting the transfer of children who require a higher level of care. Knowledge of each of these areas will help to improve the overall care and outcome of children with abdominal trauma.

Acute scrotal pain

The diagnosis of acute scrotal pain can be difficult. The most common causes include torsion of a testicular appendage, epididymitis, and testicular torsion, which account for 85% to 90% of all cases. These entities may be clinically indistinguishable because characteristic symptoms and signs for each overlap, whereas pathognomonic features are uncommon. Diagnostic accuracy without delay is required to avoid the loss of testicular function in testicular torsion cases and to avoid unnecessary surgery in other cases. A thorough understanding of the key clinical features of each entity, coupled with an understanding of the appropriate use of perfusion imaging studies, will equip the emergency physician with the tools to accomplish this task.