Ministry of health of Ukraine

Malformations and diseases of urinary and reproductive system in children.

1. Background.
Malformations of the urinary and reproductive systems are among the most frequent anomalies of childhood. According Sampbella (1951), Pytel A. (1969) they constitute 35-40% of all congenital anomalies. Difficulty embryogenesis urinary reproductive system causes a wide range of morphological and functional changes that may not manifest itself for a long time, or life-threatening in the period infant. Abnormalities of the urinary system lead to a breach of urodynamics and cause stasis of urine, which may be complicated by infection, atrophy of the renal parenchyma, renal failure and hypertension. Chastist distribution and severity of complications requires early diagnosis and implementation of rational therapeutic tactics and requires great attention of physicians and of the necessary knowledge.

2. Specific objectives of employment:

1. Master the list of diseases that cause violations of urodynamics and the act of urination.
2. Recognize the major clinical manifestations and urodynamic disorders act of urination.
3. Differentiate urodynamic disorders depending on the level of noise.
4. Interpret helper methods (ultrasound, excretory urography, cystography, scan), laboratory and biochemical analyzes.
5. Identify the peculiarities of individual defects that lead to the violation of urodynamics.
6. To analyze the causal relationships of urodynamic disorders, leukocyturia syndrome in some patients, justify and formulate preliminary clinical diagnosis.
7. Submit algorithm of the physician in violation of urodynamics and urinary disorders act.
8. Submit tactics of patients with disorders of the act of urination and violation of urodynamics.
9.Traktuvaty general principles of treatment of diseases involving violation of urodynamics and disorders act of urination.
10. Identify indications for conservative and surgical treatment of patients with malformations of the urinary and reproductive systems.
11. Master the principles of rehabilitation after surgery, be able to assess the prognosis of life possible violations after eliminating urinary tract pathology.

4.2. Theoretical questions to studies.

1. Writing definitions hydronephrosis, ureterohydronephrosis, MSR.
2. Define the concept to include the classification of anomalies of bladder and urethra.
3. Provide an explanation of the pathogenesis of urodynamic disorders due to defects kidney, ureter, bladder.
4. To characterize the clinical manifestations nosology topic.
5. Justify a choice of diagnostic activities in various forms of pathology.
6. Identify the indications for use of ultrasound, cystoscopy, cystography, excretory urography, CT, MRI, laparoscopy.
7. Determine the timing and volume of surgical interventions in various forms of urinary tract pathology.
8. Assign antibiotic therapy for urinary tract infections.
9. The algorithm of the physician in determining birth defects and tactics of the patient during the first months of life.
10. Algorithm of children's surgeon in determining congenital malformations of bladder and urethra and tactics of the patient.

4.3. Practical tasks performed in class:

1. Collect the complaint history of life and disease, to differentiate defect of depending on the level detect obstacles:
a) the presence of renal colic syndrome - pain, its nature (sharp, dull, duration, localization, distribution irradiation, the behavior and position of the patient;
b) urinary disorders: frequent, painful, difficult, urinary retention: acute, chronic, with the presence of residual urine, full, partial, a combination of delay and incontinence - ixhuria paradoxa, incontinence and nevtrymannya;
c) change the number (anuria, oliguria, polyuria, nocturia) and quality of urine (hematuria - micro and macro, pyuria or leukocyturia - true and false, total, of initial, terminal, proteinuria, cylindruria, oksaluriya, uraturia, phosphaturia;
d) hypertensive syndrome (hypoplastic kidney, polycystic, narrowing of the renal arteries).
2. Demonstrate inspection, examination of the child with the formation of the preliminary diagnosis and develop a plan of inspection sick child.
3. Master advanced research methods and interpret laboratory data and ancillary diagnostic methods.
X-ray of the kidneys its description
a) Review urography - gives knowledge about the presence or absence of radiographic calculus;
b) excretory urography shows the function and anatomical structure of the kidney and urinary tract. Intravenously injected radiopaque substance (urohrafin, verohrafin, kardiotrast, triombrast, trazohraf) averaged 50% - solution:
from 1 month to 1 year - 2 ml / kg body weight,
1 to 3 years - 1.5 ml / kg body weight,
over 3 years - 1 ml / kg body weight, but not more than 60 ml.
Photos in young children perform at 7, 20 and 40 min in older children - 10, 30 and 60 min. Kidney disease requires implementation deferred urohram in time from 1.5 to 24 hours. If necessary difdyahnostyky functional or organic changes made test with load (laziks);
c) infusion urography - 2 ml / kg body weight of contrast medium injected into the same amount of 5% - glucose drip intravenously. Infusion rate in children up to 3 years - 120-150 drops for 1 min., In older age - 100 drops for 1 min for 7-10 min. With a sharp decrease in the concentration ability of the kidneys, these figures are reduced to 60-80 drops for 1 min for 20-30 min. Indications intravenous urography age children - 2 years, reducing the concentration of kidney function, prolonged relapsing course of the disease, the lack of information in one-stage introduction of contrast material;
d) retrograde uretropiyelohrafiya proposed in 1905 Voelcker i Lichtenderg - 15% solution of contrast material, dissolved furatsilinom, injected into the renal pelvis through the urinary catheter, previously introduced by kateteryzatsiynoho cystoscope-1 year - 3 ml in 4-5 years - 5-6 ml, etc. until light discomfort around the investigated kidneys;
e) pneumoperitoneum. In 1948, Rivas offered input gas pozaocherevnyy space presakralnym way. Oxygen is administered in an amount of from 100 to 800 ml, depending on age;
e) cystography - simple or miktsiyna - gives an idea of ​​the shape and contours of the bladder, vesico-ureteric reflux, pelvis, urethra. 10% - solution of contrast medium injected into the bladder until urination urge to 2-year-old baby - 25-50 ml, 6-year-old - 75-100 ml, 10-15-year-old - 100-150 ml. Photos are performed at the time of filling and tight with urination;
g) urethrography (ascending or descending).
Methods of radioisotope diagnosis (renografiya, dystorenohrafiya, uroflowmetry, scanning).
Instrumental methods:
a) cystoscopy;
b) cystochromoscopy, based on the allocation of kidneys indigokarmina (0.4% - 1 ml to a year, then - 0.5 ml for every three years of life). Normally indyhokarmin stands for 3-5-minutes;
c) sfinkterotsystometriya - measuring the final strength of the bladder and sphincter pressure in the bladder (Rose, 1927). Enables dynamic supervision changes detrusor function;
d) urefloumetriya - the apparent speed of urination (Rehfisch, 1897). Take into account the following parameters: time urination, urinary speed. Danger instrumental methods: trauma, infection, acute uroseptic.
4. To interpret the general principles of treatment: conservative and surgical tactics in patients with developmental disabilities, urinary reproductive system.
5. Rationale for conservative treatment of patients with MCP.
6. Using auxiliary diagnostic methods, to formulate the indications for surgical treatment.
7. Characterize the composition of urine in urinary malformation of the reproductive system.
Investigation of urine by the method of AF Kakovsky (1910) / - calculated hemacyte in urine collected for 8 hours after sleep, the method of Addis (1925) - the same as in the urine per day. In normal healthy children per day in urine derive no more than 2-2.5 million leukocytes (L), up to 1 million erythrocytes (E) and to 5 thousand cylinders.
Method Amburzhe - the number of L and E in minute diuresis. In healthy children for 1 min. L appears no more than 2-2.5 thousand, E-max 1.8 thousand
Trial by A. Nechiporenko (1961) - a study of sediment in randomly selected portions of urine. Zanotovuyetsya number L and E in 1 ml of urine, which is normally on 4 th and 1 thousand Quantitative samples are very valuable for monitoring the progress of treatment after normalization of urinalysis for reveal hidden changes in it. They suggest that the process has not eliminated and needed further treatment.
Samples occult pyuria and piyelonefrity occurring latently be convincing in conducting them with prednizolonovym test (Katz, 1962), based on the fact that prednisone promotes the release of leukocytes in urine from hidden foci of inflammation in the kidney. Intravenously administered 10-15 mg (depending on the age of the child), prednisolone, dissolved in 5.10 ml of saline. Pick three servings of urine at intervals of 1 hour. Prednizolonovyy test is considered positive with increasing L and the number of degrees of total pyuria at least 3 times.
Sat urine sterility, determining the degree of bacteriuria. Availability of 50-100 thousand germs in 1 ml of urine should be assessed as a sign of inflammation in the urinary tract. If the urine is dominated by staphylococci, mostly alkaline reaction of urine; sharply alkaline - if there however. If the predominant E. coli, urine acidic reaction. The normal reaction of the urine of children with an acidic pH of 4.8 to 7.
Daily urine output. Method Zimnitskiy sets of tubular apparatus and reserve capacity of the kidneys. Take the child in the water exchange is excreted by the kidneys by 59%, skin and lungs - 34% and feces - 6%. The body is delayed about 1% to take water (A, F, Tur, 1960). At the end of the first month of life daily urine output is 200-300 ml, and 12 months - 600 ml. To determine the daily urine output in children older than 1 year using the formula:
600 +100 (n-1)
where the 600 - year-old child diuresis, n - number of years. Diuresis per day should be 2/3 of the total. The relative density of urine in infants normally is 1002 - 1008 (in the first days of life - 1018-1020), in 2-3 years - 1000 - 1017, in 10-12-years - 1012-1025. When polyuria urine less concentrated (hipostenuriya). If oliguria contrary - hiperstenuriya.
8. Demonstrate the technique of cystography.
9. Solving situational problems.

A wide range of defects and diseases of urinary-genital system determine the need for an individual approach in the diagnosis of anomalies and in determining the indications for the conservative or surgical treatment.

Diagnostic criteria for defects and genitourinary system:
Mandatory symptoms characteristic of various forms of pathology:
• Dizurichni phenomenon discoloration of urine, the presence of leukocyturia, proteinuria.
• pain (persistent pain in inflammatory complication, cramping - with obstruction), positive symptom Pasternatskogo.
• Hyperthermia complications of inflammation.
• Palpation of abdominal tumors.
Additional criteria
• Change the size, position, strain the kidneys, ureters, bladder, delayed evacuation contrast revealed by ultrasound, contrast studies stsyntihrafiyi CT, MRI, cystoscopy, laparoscopy, are decisive criteria for accurate diagnosis;
• Integrated biochemical blood to determine the degree of renal insufficiency;
• Research microflora urine needed to elucidate the nature of urinary tract infection and antibiotic therapy.
Anomalies of the urinary-genital system constitute 35-40% of all congenital anomalies. Among obstructive uropatiy in childhood he takes first place.
Hydronephrosis - a malformation that is characterized by obstruction of the pelvis-ureteral segment through its wall dysplasia, accompanied by varying degrees of underdevelopment of renal parenchyma and reduce its function.
Features of circulation, which leads to interference in prymyskovomu segment retrokavalne location ureter peryureterit, embryonic spikes, narrowing of the ureter and ureteral valve leads to disruption of urodynamics, and subsequent to the death of the renal parenchyma. The speed of this complication depends on the level of obstruction and form bowls.
Violation of urodynamic causes inflammatory changes and hardening of the kidney tissue in the area of ​​the gate kidney.
With the rapid development of occlusion hydronephrosis no time to develop. There symptom "hostrozastiynoyi kidneys", complete block of the ureter leads to increased water reabsorption in the distal tubule included piyelo-renal reflux and stop filtration in the glomerulus, open arterio-venous shunts at the border and cerebral cortical layers. Consequently stops urine of the patient.
Features of circulation, which leads to interference in prylohanochnomu segment retrokavalne location ureter peryureterit, embryonic spikes, narrowing of the ureter and ureteral valve leads to disruption of urodynamics, and subsequent to the death of the renal parenchyma and form bowls.
Option obstruction piyeloureteralnoho segment S. Bauer (1998):
A. Narrowing of the ureter by reducing the internal lumen (Intrinsic). Segmental wall ureteral dysplasia, congenital stenosis. Hanna (1976) conducted research vicious plot ureter under electron microscopy. Muscle cells are correctly oriented, but there was an excess amount of collagen fibers and the main substance around muscle cells. As a result, muscle fibers were widely separated from their places of attachment and poorly reduced (Fig. 1). Many cells are atrophied. These findings explain the ineffective contraction of the ureter in piyeloureteralnomu segment and as a result of violation of emptying bowls and cups kidney. Stephens (1980) found klapanoutvoryuyuchi transverse folds of the mucous membrane of the ureter, preventing the passage of urine. Described mucosal polyps of the ureter as a cause of obstruction Kruger (1980).

When retrograde urography observed double bend in the upper ureter. In operation revealed compression of the ureter nyzhnyepolyarnoyu vessel. (Stephens F.D. 1982).

These vessels are ahead of the pelvis-ureteral segment and compressing its lumen, causing obstruction. This cause hydronephrosis is more common in adults, ranging from 14% to 52% of Marshall (1984). In vascular barriers ureter may have several twists and prevents current urine may occur simultaneously in two places (Fig.3).
Stephens (1982) conducted a study of ureteral wall in places pressure on his vessel, but did not find evidence of fibrosis or disruption of normal anatomy of the ureter walls in these areas.

Based on these findings, it is clear that the piyeloureteroplastytsi about hydronephrosis caused abberantnoyu vessel, no need for resection of the ureter (ureteral excision site) rather move ureter during vessel to restore the flow of urine.

B. Option obstruction piyeloureteralnoho segment occurs in secondary reasons. Prolonged exposure of a plot stone prylohanochnoho of ureteral urolithiasis; traumatic injury - strain mucosa or the muscular wall of the ureter leads to impaired patency in this area. Argued vesico-ureteric reflux major steps in 10% of cases may cause local inflammation against congenital curvature of the ureter in piyeloureteralnomu segment, which further leads to narrowing and its violation of the passage of urine Blickman (1983).
Violation of urodynamic causes inflammatory changes and hardening of the kidney tissue in the area of ​​the gate kidney.
With the rapid development of occlusion hydronephrosis no time to develop. There symptom "hostrozastiynoyi kidneys", complete block of the ureter leads to increased water reabsorption in the distal tubule included piyelonyrkovi reflux and stop filtration in the glomerulus, open arterio-venous shunts on the verge of cerebral and cortical layers. Consequently stops urine of the patient.
Clinical classification of hydronephrosis.
We must distinguish three degrees of hydronephrosis: Class. II and III levels.
And degrees - hydronephrosis characterized by expansion renal pelvis, the lack of anatomical changes parenchyma;
Second Degree - Expansion cups and renal pelvis, reducing the thickness of the parenchyma, decreased intensity of staining of abdominal kidney nefrofazy, decreased tubular secretion and does not exceed 70-80%.
Third degree - is characterized by the expansion of cups and bowls by significant thinning of kidney tissue, sometimes to its complete absence, lack of contrast, reduced tubular secretion of more than 80%.
Diagnostic criteria syndrome piyeloureteralnoho segment:
Mandatory symptoms:
• Palpuyema tumor in the lateral abdominal
• Changes in the urine sample
• Repeated abdominal pain
Additional criteria:
• Dizuricheskih disorders (urinary retention, urinary incontinence, compelling urge, weakened urine stream or its termination)
• Hematuria
• Unexplained changes in the gastrointestinal tract (nausea, vomiting, abdominal pain)
• Edema
• Delayed physical development
• Nocturia
• Thirst
The main diagnostic methods used for suspected hydronephrosis - a ultrasound and X-ray examination. To clarify the diagnosis used radioisotope and laboratory diagnostic techniques. The data obtained help in detecting inflammation and installing gravity renal dysfunction.
Given the large regenerative possibilities child's body, even at partial purulent fusion parenchyma or partial loss of function, please try to keep hydronephrosis kidney. By reducing kidney function at 4/5 (according to radionuclide studies) perform nephrectomy. In other cases, conducting resection pelvis-ureteral segment overlapping anastomosis between the pelvis and ureter. With hydronephrosis, the occurrence of which is associated with the presence of additional vessels, the last move so he squeezed anastomosis.
Methods of operation.
1. In the treatment of hydronephrosis of choice (the gold standard) remains plastic pelvis of the ureter by Hines Andersen.

Important in the treatment of renal colic at the clinic to be able to provide medical care that can occur in acute, sudden injury to the outflow of urine from the renal calyces and pelvis (obstruction of stone, mucus and pus, blood clot, compression of the ureter Nephroptosis). The immediate cause of pain in renal colic - acute circulatory disorders in the kidney (venous stasis, edema, stretching the fibrous capsule).

Syndrome of renal colic can refine research urinalysis, blood, holding Overview radiographs of the urinary tract, except for acute inflammatory diseases of the abdominal cavity.
In establishing the syndrome of renal colic shown:
a) heat treatment (hot water bottle, bath);
b) injection of atropine (0.1% solution of 1 mol per year of life), antispasmodic, analgesic administration - Drugs (promedol 2% - 0.05 mol per year of life), analgesics (50% analgin - 0.1 mol per year of life, baralgin);
c) novocaine blockade sim'yannoho cord or the round ligament of the uterus. Technology blockade: the thumb and index fingers of the left hand are sim'yannyy cord in his inguinal-moshonkoviy region (near the root scrotum) or form a skin folds in the groin in girls. Right hand injected using a syringe from 5 to 20 mol% 1 - novocaine solution depending on age;
d) recommend increased fluid intake, increased diuresis activates the contractile activity of the ureter, increasing the possibility of expulsion of stone, sand, blood and pus bunch.
Successful treatment depends on timely detection of hydronephrosis and preservation of kidney function. After 6-12 months. after surgery, depending on the patient's general condition and associated flow control pyelonephritis conduct examination (ehoskanuvannya or excretory urography). Children who underwent surgery for hydronephrosis, advisable to spend on spa treatments (Truskavets or Zheleznovodsk specialized local motels).

Bladder-ureteral reflux (MSR)

Defects, which cause reverse flow of urine, observed in 60% of children. Vesico-ureteric reflux is bilateral: if a 60 - 70% of patients with relatively early he manifested renal hypertension and chronic renal failure. Timely diagnosis and treatment of children with this pathology is responsible enough problem with timely addressing any possible organ surgery.
Primary MSR resulting from insufficient locking mechanism vesico-ureteral connections. Violations occurring in the fetus during the last months of pregnancy, leading to disruption of fetal development with subsequent dysplasia nephron.
Secondary MSR, which occurs due to an increase vnutryshnomihurovoho and vnutryshnomyskovoho pressure leads to disruption of venous and lymphatic drainage parenchyma.
Throwing infected urine to the ureter in the pelvis-Wire cup system kidney inflammation leads to renal parenchyma. There is swelling of the parenchyma, proliferation of connective tissue in paravaskulyarnomu space increases ischemia nephrons and develops scarring parenchyma.
The clinical picture without pyelonephritis may be asymptomatic. In the presence of clinical signs of recurrent exacerbation isolated reflyuksohennu nephropathy. Changes in urine - leukocyturia, erytrotsyturiya sometimes are also a sign of MSR.
The most reliable method of diagnosis that confirms MSR - is a simple and miktsiyna tsystohramy, cystoscopy. Excretory urography, radionuclide renografiya confirm the severity of the violations of malformations.
The therapeutic approach is based on data on the genesis of MSR, the degree of renal dysfunction, the presence of activity piyelonefritu.
At MSR I - II degree without impaired renal function at the location ustiv ureters in the typical location - conducted conservative treatment.
Inefficiency conservative treatment MSR third degree within 6 - 8 months needs revision tactics and determine the need for surgical correction. Methods of tsystoneoureterostomiyi by Cohen, Boari.
When megaloureter, ureterohydronephrosis IV - V neotsystureterostomiya degree held by the Politano-Leatbetterom.
One of the methods of choice for treatment of children with MSR I - III degree - endoscopic summing gel Teflon paste - into the bladder wall above the mouth of the ureter.
Malformations of the urethra and bladder.
Chastist malformations of the genitourinary system and the complications that arise from this disease, recognize the importance of early detection and treatment of this pathology.

Abnormalities of the structure of the urethra, its partial or complete absence of the wall of the urethra, chordee, meatostenoz first cause violation of the act of urination in subsequent violations result in urodynamics. Chastist defects such as posterior urethral valve, epispadiya, hypospadias, phimosis, paraphimosis very diverse, but its timely diagnosis and determination of treatment strategy - an important diagnostic and responsible problem.

Auxiliary diagnostic methods (excretory urography, cystography, ureterotsystoskopiya) help in diagnosis. An examination of children with disorder act of urination is very important tsystometriyu, ureterotonometriyu, uroflometriyu and evaluate them.
Complications:
1. Infravezykalna obstruction leads to increased vnutrishnomyskovoho pressure and disruption of the kidneys, the venous and lymphatic circulation, loss of renal parenchyma.
2. Disorders of the act of urination leading to incontinence infection that enters through rising to the bowl kidneys, causing its inflammation, and further scarring of kidney tissue.
3. Defining the indications for conservative or surgical treatment is based on the general principles of treatment of children with developmental disabilities, urinary-genital system. The method of surgical intervention is justified defect, age of the child and the changes that occurring as a result of the disease.
In disorders of urination, urinary retention - inability to self-emptying of the bladder, strong and useless urination, overflow, stretching the bladder, severe abdominal pain, reflex slowing of the intestines is necessary to differential diagnosis of urinary retention and anuria. The content and purpose of first aid for urinary retention is in emptying the bladder by catheterization, which should always begin with the application of soft rubber catheter. Caliber urethral catheters characterized by specific numbers (scale Sharera). Most catheter - is the length of its circumference (in millimeters 2 Pg). Types of catheters: catheter Nelatona, Timan catheter, Foley catheter, metal catheter.
Technology catheterization. If you enter a metal catheter can not be safer to abandon further efforts and make nadlonnu puncture the bladder ("capillary puncture"). Carry it in the patient's back. After processing the suprapubic area with a sterile needle in a strictly perpendicular to the direction or angle 450, open down, pierce the anterior abdominal wall in the midline 2 cm above the pubic area.
Extrophy bladder characterized by a defect of abdominal wall, absence of the anterior bladder wall and its cavities, total hypospadias, nonunion lonnyh bones. Chastist this pathology in children 1 from 40000-50000 newborns. In boys, this pathology occurs 3 times more often than girls. This malformation is often combined with cleft and hypoplasia of the labia and vagina in girls, underdeveloped penis, cryptorchidism or inguinal hernia, rectal prolapse - boys.
Clinical specific: in the lower abdomen above the pubis through rounded defect in the anterior abdominal wall explodes mucosa of the bladder, its rear wall, which increases during crying and when natuzhuvanni. Navel missing or placed on the top edge of the defect. Mucosa is painful and bleeds. Dimensions sechomihurnoyi plate 3-7 cm in diameter, on it is a triangle l'yeto Wust and ureters. Urine flows continually, causing skin maceration thighs and crotch.
Having contact with the external environment ureters leads to ascending pyelonephritis.
Treatment of patients with urinary bladder extrophy very problematic associated with great difficulty. The optimal time for surgery after the age of 1 year.
Epispadiya - is a congenital malformation that is characterized by partial or complete absence of the anterior wall sechovypusknoho channel. Chastkist this pathology - 1 of 50,000 newborn boys 5 times more often. When epispadiyi underdeveloped penis, deformed, his head flattened and bifurcated. Foreskin his overly developed and located only on the ventral surface.
Depending on the degree of splitting of the urethra are three forms epispadiyi boys:
a) epispadiyu head b) epispadiyu penis in) complete (total) epispadiyu. In girls isolated klitornu subsimfiznu and complete (total) epispadiyu. Total epispadiya occurs 3 times more often than other forms.
Epispadiya head is characterized by flattening the head, splitting the foreskin top offset hole to urethra level vinuevoyi borozdy.
When epispadiyi penis there chordee, head split from her on the back member extends streak strip shell to dystopovanoho hole urethra. Opening of the urethra is shaped like a funnel. Sphincter of the bladder, usually weak and partially split, so when you cough, laugh and exercise marked neutrymannya urine. The act of urinating broken. The patient can urinate sitting down, pulling the foreskin of the penis backwards, urine sprayed. Penis cut and pulled up to the belly due to differences recti legs that attach to lonnyh bones. Lonnie bone nezroscheni.
Full epispadiya characterized by underdeveloped penis that looks like crochet, smart top. Cavernous body split, the entrance to the bladder is shaped like a funnel. Sphincter split ring as observed complete neutrymuvannya urine. Great diastase between Lonnie bones leads to "duck walk." In this wadi development can be observed malformations of kidneys and ureters, cryptorchidism, testicular ectopia and prostate.
Epispadiya girls. This malformation is characterized by smaller anatomical abnormalities, so it is more difficult to diagnose. In total epispadiyi upper wall of the urethra is absent throughout and sechovypusknyy channel looks trough. Bladder neck and symphysis split. Urine flows continuously without causing maceration.
When subsymfizarniy epispadiyi is complete cleavage clitoris, external opening of the urethra opens on him in the form of a funnel. For this disease is characterized by complete or partial incontinence.
Klitorna form is characterized by the splitting of the clitoris, the external opening of the urethra shift doperedu and top. Urination is not broken.
Treatment consists in the fact that to achieve retention of urine and form a missing part of the urethra.
Holovchata form epispadiyi klitorna girls and does not require treatment. Other surgical procedures are carried out not earlier than 4-5 years.
Hypospadias - a malformation of the anterior urethra, where missing its rear wall and the external opening of the urethra is narrowed and shifted proximally and opens on the ventral surface of the glans penis (hypospadias holivchata) or perineum (perineal hypospadias form). Penis deformed, bent down in the form of "hooks". This malformation occurs in a newborn at 300-1200. Hypospadias is more common in boys than in girls. The external opening of the urethra in girls opens into the vagina. It can be observed neutrymannya urine in the splitting of the sphincter of the bladder.
Hypospadias in 40% of cases spoluchuyetsya with other anomalies of development, including the top ranked cryptorchidism. It is necessary to complete clinical examination of children.
AE Solovyov identifies 3 forms of hypospadias in girls: vestibular (partial) vestybulopihvynna (subtotal), inguinal (total).
Operative intervention is performed in one or more stages. When meatostenozi-meatoplastyka performed regardless of age. Indication should prevent secondary changes. Roztynannya narrowed external opening of the urethra can be performed and outpatients. Treatment depends on the form of hypospadias and performed in several stages. Optimal duration of the first phase of 1.5-2 years uretroplastyku performing at the age of 6-7 years.
Phimosis. Narrowing of the opening of the foreskin, the glans penis which does not appear in children is common and is called phimosis. In infants and young children observed adhesion outer layer of the foreskin and the glans penis that does not allow open foreskin. During the first 3 years of life, this phenomenon is called "physiological" and do not require treatment.
Congenital phimosis called impossibility retraction of the foreskin and the glans penis withdrawal at age 3 years. Acquired phimosis develops due to infection and inflammation of the preputial sac at the edges of the hole (cicatricial phimosis).
When phimosis children complain of pain during urination and itch in the area of ​​the penis. On examination, the skin is very narrow hole through it visible only external opening sechovypusknoho channel diverting the foreskin brim and open crown impossible. When urinating marked swelling preputial sac. The condition can lead to enlargement of the upper urinary tract, complicated paraphimosis, balanitis. In infants with complaints of itch and pain when urinating appointed by conservative treatment: sitting in a warm bath, smearing vaseline oil foreskin. If no effect spend separation synechiae foreskin puhovychnym probe head smeared vaseline oil, continue soaking with potassium permanganate.
In cases of congenital or acquired phimosis in older children in the presence balanytu and urinary retention performed surgery - circular circumcision.
Balanyt (balanopastyt) - inflammation of the foreskin and the glans penis. This disease most often occurs in congenital phimosis. Cluster rozlahayuchoyi smegma and urine preputial mishtsi, ssadnennya rozchosy and lead to the development of inflammation.
The patient complains of itch and hurt when urinating. An objective examination determined locally irritation, mild redness and swelling. These characteristic symptoms of catarrhal balanytu. When conducted properly treating all these things disappear, but may recur.
With insufficient child care and non personal hygiene boil can get to the preputial sac. Developed purulent infection glans penis. Pus accumulates in preputial mishtsi, causing severe irritation, pain, and even urinary retention.
In introducing the process of developing swelling of the foreskin and penis, which becomes thickened clavate. The skin can be seen hiperemiyiyi areas that chereduvalysya with normal coloring (lymphangitis). The head is covered by the foreskin, determined fluctuations.
Treatment. When catarrhal balanyti held sitting baths with antiseptic 2 times a day before subsiding inflammation. When purulent inflammation is necessary to surgery. The opening of the foreskin to expand the clamp or forceps, last viddvynuty brim and open crown. According to probe bellied adhesions disconnected. Provided festering mass, head cleaned and smeared vaseline oil, the foreskin would happen. Conducted bath until subsiding inflammation. If balanyt repeated, it is necessary to circular circumcision in the cold period.
Paraphimosis - is a condition where there is pinching the glans penis in the opening of the foreskin. This phenomenon is more common in phimosis, and as a result of mastering or misbehavior child when viddvynuta foreskin can not fall because of the narrowness of the hole. Ring opening falls into venechnu borozdu and squeezes, zaschemlyaye glans penis. Venous stasis develops very quickly, it swells and grows in size. Further swells whole penis.
The clinical picture is characterized by a pronounced local changes. The child complains of severe pain, standing with legs apart and bent trunk doperedu. Penis enlarged and deformed head cyanotic. Above venechnoyu borozdoyu is dramatically swollen and hyperemic foreskin, which looks like two circular ridges separated by deep borozdoyu.
Palpation - sharp pain, possible zatrudnene urination.
Late assisting in 3-4 days from the date of a possible pinched skin necrosis in the area pinched ring, in severe cases - necrosis of the head.
Treatment. Needed overnight reposition head through zaschemlyayuche ring and moving the foreskin to habitual. In very advanced cases and restless children this manipulation is performed under general anesthesia.

Materials for self-

Situational tasks
Task 1. The boy in '12 for a week - abdominal pain, fever to 38.50 C in the urine sample - leukocyturia, proteinuria. On ultrasound - expansion cup-pelvic left kidney.
1. Your diagnosis?
2. What additional surveys are needed to clarify the diagnosis?
3. The main causes of the disease.
4. Clinical manifestations.
5. Tactics treatment and patient management.

Task 2. A child 5 years of 3-year old recurrent colicky abdominal pain, vomiting, frequent urination, fever up to 38oS and more. Catarrhal no stool is normal. In the clinical analysis of urine - leukocyturia, bacteriuria. When miktsiyniy cystography filled expanded ureter.

1. Formulate a diagnosis.
2. What additional test?
3. What diseases should be a differential diagnosis.
4. Tactics treatment.

Problem 3. The boy 6 years of frequent abdominal pain with changes in urine (leukocyturia). An excretory urography. A marked expansion of renal cups and bowls left. Miktsiyna cystography - no pathology.

1. Formulate a diagnosis.
2. What additional test?
3. What diseases should be dyf.diahnostyku.

Problem 4. Child 6 years old, suffers from enuresis in urination complains of pain in the left lumbar region. Rhythm urination accelerated with mandatory call. In the analysis of urine - periodically leukocyturia, bacteriuria. With ultrasound - left kidney dramatically reduced in size, elegant parenchyma.

1. Formulate a diagnosis.
2. What additional test?
3. What diseases should be a differential diagnosis.
4. Tactics treatment.

Problem 5. The boy, 1 month of life is determined by urinary retention, two-phase urination. The examination - in urine - leukocyturia. Sonolohichno - large bladder, both ureters dilated and renal pelvis.

1. Formulate a preliminary diagnosis.
2. What is necessary to survey methods?
3. With what diseases you spend a differential diagnosis?

Problem 6. The boy 6 years old, suffering from frequent abdominal pain, changes found in the urine sample - leukocyturia, pyuria. In somatic compartment held excretory urography. X-rays revealed a significant expansion of cups and bowls left.

1. What is the most likely diagnosis?
2. What is necessary to conduct additional tests?
3. What treatments.

Problem 7. The child is 3 years with periodic abdominal pain and pyuria ultrasound revealed enlarged left kidney and rounded cavity, coupled with extended bowl. The right kidney is not changed.

1. What diagnosis is correct?
2. Perelikuyte necessary methods.
3. What diseases should conduct a differential diagnosis?

Task 8. In children surgical department hospitalized boy aged 1 month, which prenatally diagnosed left-sided piyeloektaziyi. Based on data analysis, drip infusion urography, cystography, ultrasonography of the child revealed hydronephrosis initial stage. Data on secondary pyelonephritis there.

1. What tactics is appropriate on this patient?
2. What methods can help in determining the tactics of the patient?
3. Perelikuyte treatments that can be applied in this case.

Problem 9. Patient complains of '15 dull pain in the right kidney, fever, pouring sweat and body temperature to 39 ° C. OBJECTIVE: heart rate - 120 beats / min., Ar ¬ terialnyy pressure - 100/60 mm Hg Abdomen soft. Kidneys not palpuyuyetsya in 3 positions. Pasternatsky positive thing. In urine - protein 0.066 g / l, WBC 50-60 in sight, erythrocytes 1-2 in sight. Growth of E coli flora 100 thousand in 1 ml. Ultrasound - the size and thickness of the right kidney parenchyma increased, increased echogenicity.

1. What is the most likely pathology?
2. What methods of diagnosis should hold in dynamics?
3. Perelikuyte treatments.
4. What are the complications that can arise.

Problem 10. In urology department received little girl 2 months with complaints of fever, vomiting, refusal of food. With ultrasound examination of the kidneys, excretory urography revealed megaloureter. In Urinalysis - leukocyturia, proteinuria, blood - neutrophilic leukocytosis with a shift to the left.

1. What is the most common cause of megaloureter in children?
2. What examination is necessary to determine for medical treatment?
3. Treatments megaloureter.
Problem 11. The boy 6 years has been an increase of the size of the right half of the scrotum. Palpable soft-elastic formation and painless. Percussion gives a dull sound. Mother marks an increase of formation of exertion.
1. Your diagnosis.
2. Tactics treatment.
3. What additional instrumental method helps in diagnosis?
4. Up to what age children with such disorders do not operate?
5. Differential diagnosis.

Task 12. The boy 8 years complaint narrowing of the foreskin, the impossibility of removing the head of the penis.

In history - inflammation in this area. Foreskin scar changed head not displayed.
1. Your diagnosis.
2. Your tactics?
3. Plan Survey.
4. The treatment plan.
5. Can effective conservative treatment without surgery?

Problem 13. The boy 4 years - swelling and redness of skin foreskin hnoyevydilennya. The head of the penis does not open, narrowed foreskin.

1. Your diagnosis.
2. Likely cause.
3. Your tactics?
4. The essence of conservative therapy.
5. Most complications in the derivation of the glans penis in a child with phimosis.

Problem 14. The boy 2 years - atypical location of the external opening of the urethra, in the area of ​​stem penile chordee. During urination child stiffens.

1. Your diagnosis.
2. Your tactics.
3. What are the optimal time meatotomiyi.
4. What is a primary feature of hypospadias?
5. What hypospadias does not need surgery?

Tests
1. Child, 8 years old was admitted to hospital complaining of pain in the right lumbar region. Ill during one year. During the X-ray examination revealed a significant increase Wire cup-pelvic, which is typical for hydronephrosis third degree. Contrast ureter can not be traced. What in this case is the most likely cause of these changes?

A. stricture ureter.
V. urethral valve
S. pyonephrosis.
D. Injury to the kidneys.
E. diverticulum of the bladder.

2. In the hospital approached the parents of the child 1 month, in which the prenatal period with sonolohichnomu examination revealed enlargement Wire cup-pelvic. From what method should begin screening children?

A. Excretory urography.
V. cystography.
S. Sonolohichne examination, laboratory examination.
D. Laboratory examination.
E. Cystoscopy.

3. The child is 3 years old ultrasound kidney revealed a significant increase in the left kidney and extending Wire cup-pelvic in urine observed leukocyturia, proteinuria. What method should be undertaken for confirmation of the diagnosis?

A. cystography.
V. Ureterotsystoskopiya.
C. Excretory urography with the load.
D. Magnetic resonance imaging.
E. Doppler vascular kidney.

4. To the hospitals received girl 10 months with fever, intoxication syndrome. The examination of blood tests - leukocytosis, leukocyte left shift in the urine - leukocyturia, proteinuria, sonolohichno - increasing left kidney, a significant expansion pelvis and calyces. With what diseases you spend diffusion. difahnostyku?

A. Polycystic kidney disease, urolithiasis.
B. Left-hand ureterohydronephrosis.
C. Valve posterior urethra.
D. Bladder-ureteral reflux.
E. Ureterotsele left ureter.

5. Girl 5 months neodnarozovo came to the physical separation of fever, intoxication syndrome, vomiting, diarrhea. An examination of laboratory - leukocyturia, proteinuria and urine; leukocytosis - in blood. With ultrasound examination revealed piyeloektaziyu on both sides, enlarged ureters in the prostate area. What method of diagnostic help in diagnosis?

A. Cystoscopy.
V. cystography.
S. Sonolohichne examination, Doppler.
D. Ureterotsystohrafiya.
E. Uroflometriya.

6. By urologist requested parents of a newborn child with complaints of delay and dvuhfaznist urination. In Urinalysis - leukocyturia, proteinuria. When ultrasound of the kidneys and urinary shlihiv - significant expansion pelvises of both kidneys, ureter expansion at the top and bottom third, increased the size of the bladder. What preliminary diagnosis can be suspected?

A. Bilateral megaloureter.
V. Bilateral refluxing ureterohydronephrosis.
S. bladder-ureteral reflux.
D. Valve posterior urethra.
E. diverticulum of the bladder.

7. Girl 1 year, was admitted to the urology department with complaints of fever up to 39-40oC, intoxication syndrome, leukocyturia, proteinuria. On ultrasound - expansion cup-pelvic both kidneys, ureter expansion in the lower third. What diagnosis can be suspected?

A. Bilateral ureteral reflux-bladder.
V. Bilateral hydronephrosis.
S. megaloureter.
D. Bilateral ureterohydronephrosis.
E. diverticulum of the bladder.

8. Boy 10 months, was admitted with clinical pyelonephritis. When examining expansion sonolohichnomu Wire cup-pelvic left kidney, ureter expanded in the lower third. Suspected left-bladder-ureteral reflux. What method of diagnosis confirm this diagnosis?

A. cystography.
V. Ureterotsystohrafiya.
S. Ekstretorna urography.
D. Cystoscopy.
E. Uroflometriya.

9. Child 8 years old suffering from enuresis, the survey sonolohichno - revealed enlargement Wire cup - pelvic left kidney, reducing the left kidney parenchyma sophisticated. The diagnosis of left side bladder-ureteral reflux. What method should be undertaken for evaluation function of the left kidney?

A. Laboratory testing.
B. Excretory urography, radioisotope examination.
S. Cystoscopy.
D. Ureterotsystohrafiya.
E. Uroflometriya.

10. In the newborn child during sonolohichnomu examination revealed enlargement Wire cup-lohanochno of left kidney and left ureter formation 1,5 x1, 0 cm in the bladder. Which test is necessary to first?

A. Excretory urography.
V. Miktsiyna tsystohrama.
S. renography.
D. Cystoscopy.
E. Laboratory testing.

11. On examination, the newborn boy midwife noticed changes in the penis. Head flattened, tucked to the scrotum. Scrotum open. Skin preputial sac and rear. The external opening of the urethra is on the midline squashed scrotum. What is the diagnosis?

A. Moshonkova form of hypospadias.
V. Epispadiya.
S. extrophy bladder.
D. Fistula urahusa.
E. perineal hypospadias form.

12. Parents are a child of 4 years, turned to the surgeon with complaints of frequent inflammation of the foreskin and the presence of painful urination with. On examination - foreskin elongated, hypertrophied, bringing the glans penis is difficult and painful. What method of treatment used in this case?

A. Operation Shloffera.
V. Tsyrkumtsizio.
C. Operation Rozera.
D. Operation Sokolova.
E. Ross operation.

13. In the hospital received a boy, 7 years, with complaints of acute urinary retention. In the history of frequent balanopastyty, urinary retention, sluggish stream of urine. On examination, genital marked a sharp narrowing of the external opening of the bag, the head of the penis is not derived from external opening preputial sac, inflating preputial sac when urinating. What method of treatment should be used?

A. Tsyrkumtsizio.
B. Operation Rozera.
C. Operation Shloffera.
D. Separation sinehiy.
E. Conservative treatment.

14. Born a boy weighing 3100 g. On examination, the child is determined underdevelopment right scrotum, palpation and sonolohichno-no right testicle. Left testicle palpated in dilyatsi external opening of the inguinal canal. Which form developmental abnormalities include congenital absence of testicles?

A. monorchism.
B. Hypoplasia of testis.
S. Agenesis testicles.
D. Anorhizm.
E. Cryptorchidism.

15. On examination, the surgeon boy 6 months revealed asymmetry of the left scrotum, no left testicle palpation - in the groin area smooth, supple tumor formation. What is the optimal age for treatment recommended surgeon father of the child?

A. 2.5 - 3 years.
B. 1 year.
S. K 2-m years.
D. 5-7 years.
E. 10 years old.

Checklist

1. How to identify a patient with renal colic syndrome?
2. What all types of urinary disorders.
3. What qualitative changes in urine determined in patients with malformations of urinary system?
4. What method of study and test for latent pyuria you know?
5. Indications for instrumental methods.
6. What clinical symptoms are abnormalities of renal vessels?
7. What clinical symptoms are abnormalities of the kidneys and Wire cup-lohanochno system?
8. What abnormalities lead to the emergence of vesico-ureteral reflux?
9. What abnormalities that lead to the violation of urodynamics of the upper urinary tract.
10. What should be considered when prescribing antibiotic therapy, how to assess the degree of its effectiveness?

Practical tasks.

1. Be able to identify the syndrome of renal colic, to palpation of the lumbar region and provide medical assistance for acute sudden violation of the outflow of urine from the upper urinary tract.
2. Conduct a differential diagnosis of urinary retention and anuria, if necessary, emptying the bladder catheterization or to make nadlonnu puncture the bladder.