Urethral Disorders

retrograde, ureterovesical, pressure, valve, UTI

Vesicoureteral Reflux (VUR)

• ___________ passage of urine from the bladder into the upper urinary tract

• Normal:

  • Urine enters the bladder but the _________________ junction prevents urine from regurgitating into the ureter

  • Protects the kidney from high ___________ in the bladder and from contaminated urine

• Abnormal:

  • Incompetent ______ leads to reflux of urine into the ureter

  • Significantly increases the chance of ___ and kidney damage

ureterovesical, short, growth

Primary VUR

• Most common

• Incompetent or inadequate closure of the _______________ junction

  • Congenitally _____ intravesical ureter

  • Spontaneously resolves with patient _______

pressure, contraction, obstruction, >, >

VUR: Secondary and Epidemiology

• Secondary

  • Abnormally high voiding __________ in the bladder which results in failure of the UVJ to close during bladder _____________

  • Associated with anatomic or functional bladder ____________

• Epidemiology

  • Caucasian _ AA

  • Female _ Male

hydronephrosis, febrile UTI, females, bowel, bladder

VUR Clinical Presentation

• Prenatal presentation

  • ______________ on prenatal ultrasonography

• Postnatal presentation

  • Postnatal diagnosis of VUR is usually made after a diagnosis of a ________ ___

• Older toilet-trained children, especially __________, with VUR diagnosed after an initial UTI have a higher likelihood of having _______ and _________ dysfunction (BBD)

voiding cystourethrogram (VCUG)

What is the preferred diagnostic tool for VUR?

Grade I

VUR Grades

• reflux only fills the ureter w/o dilation

Grade II

VUR Grades

• Reflux fills the ureter and the collecting system w/o dilation

Grade III

VUR Grades

• Reflux fills and mildly dilates the ureter and the collecting system with mild blunting of the calcyes

Grade IV

VUR Grades

• Reflux fills and grossly dilates the ureter and the collecting system w/ blunting of the calcyes. Some tortuosity of the ureter is also present

Grade V

VUR Grades

• Massive reflux grossly dilates the collecting system. All the calices are blunted w/ a loss of papillary impression, and intrarenal reflux may be present. There is significant ureteral dilation and tortuosity.

pyelonephritis, renal, surveillance, prophylactic, bactrim, cephalexin, surgery

VUR Treatment

• Goals

  • Prevent recurrent _____________ and UTIs

  • Prevent further ______ damage

  • Identify and treat children with bladder or bowel dysfunction

• Grade I-II

  • Toilet Trained: ___________

  • Not toilet trained: _____________ antibiotics

• Abx Prophylaxis

  • >2 months: ________ or nitrofurantoin

  • <2 months: _____________

• Grade III-V

  • Abx prophylaxis

  • _________ indications

    • Continued grade IV/V beyond 2-3 y/o

    • Children who fail medical therapy

    • Children who have side effects from continuous abx

    • Those who are noncompliant with meds and f/u

congenital, ventral, ectopic, curvature, foreskin, prepuce, glans, scrotum

Hypospadias

• _____________ anomaly resulting in abnormal __________ placement of the urethral opening

• Defined as any or all:

  • _________ urethral meatus

  • Penile _____________ (chordee)

  • Ventral __________ deficiency with incomplete foreskin closure around the glans, leading to the appearance of a dorsal hooded ________

• Location

  • Anywhere within the ______, the shaft of the penis, the _______, or perineum

androgenic, metabolism, estrogen, estrogenic, age, DM, pesticide

Hypospadias

• Pathogenesis

  • Disruption of ___________ stimulation

• Genetic

  • Gene mutations that affect androgen ____________ and __________ and androgen response

• Environmental

  • Prenatal exposure to __________ compounds

• Risk factors

  • Advanced maternal ___

  • Preexisting maternal __

  • Family hx

  • Smoke and ___________ exposure

  • Prematurity

  • Fetal growth restriction

  • Placental insufficiency

sexual, pelvic, karyotyping, electrolytes

Hypospadias

• If severe hypospadias or hypospadias with cryptorchidism

  • Concern for a disorder of _______ development

    • _______ US

    • ___________

    • Serum _________ w/ further eval for congenital adrenal hyperplasia

functional, deflection, standing, curvature, fertility

Hypospadias Referral and Correction

• Reserved for pts with ____________ issues

  • Significant ___________ of the urinary stream

  • Inability to urinate from a ________ position

  • Erectile dysfunction d/t penile ____________

  • ___________ issues

forme fruste, surgery, required

Hypospadias Classifications

• _____ ______

  • NO surgical correction

• Standard

  • Depends on urethral location and penile curvature

  • _________ may or may not be needed

• Severe

  • Surgery ___________

tubularization, TIP, 2

Hypospadias Techniques

• Standard Hypospadias

  • Primary _______________ (tubularized urethroplasty) with or w/o ___ (tubularized incised plate)

• Severe Hypospadias

  • Onlay Island Flap

  • _ stage repair

dorsal, glans, incontinence, symphysis, sulcus, groove, penopubic, glans

Epispadias

• _______ location of the urethra

• Classification

  • Glandular

    • Urethra opens on the dorsal aspect of ______

    • Rarely have _____________

  • Penile

    • Urethral opening located between the pubic _________ and the coronal ______

    • Broad and gaping opening

    • Usually have a distal ______ from the meatus to glans

    • 75% have incontinence

  • Penopubic

    • Urethral opening at the _________ junction

    • Dorsal distal groove through penis to ______

    • 95% have incontinence

exstrophy, surgery, chordee, glans

Epispadias

• Often associated with bladder _________

• ________ is required to correct the incontinence, remove _______, and extend the urethra out onto the _____

meatus, pendulous, bulbar

What are the parts of the anterior urethra?

Membranous, prostatic, bladder neck

What are the parts of the posterior urethra?

meatus

1

pendulous urethra

2

Bulbar urethra

3

Membranous urethra

4

Prostatic urethra

5

Bladder neck

6

stream, incomplete, spraying, UTIs, postvoid, stones, hydronephrosis, fistula

Urethral Stricture

• Obstructive Voiding Symptoms (MC)

  • Decreased urinary _______

  • ___________ bladder emptying

• Other symptoms

  • _________ of urinary stream

  • Recurrent ____

  • Dysuria

• Complications

  • Elevated _________ residual urine volumes

  • Bladder _______

  • UTIs

  • ________________

  • Urethral _________

  • Abscess

low, high, cystourethroscopy, anterior, posterior

Urethral Stricture Diagnostics

• Uroflowmetry

  • ___ peak urine flow rate

• Post void residual (PVR)

  • ____ PVR

  • Postvoid volumes of 50-100 mL may indicate an abnormality

• __________________

  • Used before treatment to further define stricture

• Retrograde urethrogram (RUG)

  • Most useful at assessing the _________ urethra

• Voiding cystourethrogram (VCUG)

  • Most useful at assessing the _____________ urethra

• US urethrography

dilation, urethrotomy, high, reconstruction, diversion, suprapubic

Urethral Stricture Treatment

• Minimally Invasive (most common initial Tx)

  • Urethral __________

  • Endoscopic _____________

• ***____ rate of recurrence

• Invasive

  • Urethral ________________ (urethroplasty)

• Other

  • Urinary ___________

    • ____________ tube placement

    • Perineal urethrostomy

eversion, mucosa, postmenopausal, unknown, estrogen, valsalva

Urethral Prolapse

• Circumferential _________ of the urethral ________ at the urethral meatus

• Epidemiology

  • Prepubertal and ______________ females

• Etiology

  • _________ mostly

  • Possibly from ___________ deficiency

  • Result of ________ voiding or constipation

  • Loose connections between muscle layers of urethra

painless, urinary, beefy red donut

Urethral Prolapse Signs/Symptoms

• ___________ bleeding

• Can become painful or cause __________ symptoms

• ______ ___ _____ shaped protrusion

observation, estrogen, sitz, cauterization, foley, ureterocele

Urethral Prolapse Treatment

• Conservative

  • ____________, topical _________, and/or anti-inflammatory creams, and ____ baths

    • 67% recurrence rate of non-operative treatment

• Surgical

  • _______________, ligation around a ______ catheter, and complete circumferential excision

• After reduction, cystoscopy should be done to r/o ____________