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An Analysis of 2403 Consecutive Pediatric Urological Consultations
THE JOURNAL OF UROLOGY
Vol. 87, No. 1 January 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in U.S.A.
AN ANALYSIS OF 2403 CONSECUTIVE PEDIATRIC UROLOGICAL CONSULTATIONS JOHN M. TUDOR, OSCAR W. CARTER, ROBERT E. McCLELLEN
AND
TOM E. NESBITT
or calculus. Therefore, chronic pyelonephritis may be a more appropriate diagnosis in this instance. Naturally, many of the patients in whom the diagnosis was urinary tract infection or bladder neck syndrome initially or subsequently had symptoms and signs of acute pyeloncphritis (table 1). The anomalies listed in tables 2, 3 and 4 do not include normal reduplications. The large number of urethral and bladder anomalies (table 4) includes all degrees of hypospadias. The number of cases of cryptorchism and hyclrocele (table 5) is perhaps small for this series. l\!Iany of these arc seen by general surgeons in our community. The large number ot cases of meatal stricture is again noted, the most common lesion in the male child. madder neck obstruction includes all degrees of severity from mild to those creating severe obstruction and profound upper urinary tract damage. Our series of \Vilms tumors is likewise small (tabl0 5). Many of these patients, especially those who present with an abdominal nmss, are seen by general surgeons. Genital injury runs the gamut; mild to severe, as do vesicourethral and renal trauma. The vesicovaginal fistula was a sequcla of transurethral bladder neck resection. Calculous disease is not common in children (table 6). N"o vesical stones incident to catheter or foreign body are included. Diabetes mellitus was seen in 2 conneetions; polyuria, and coma thought to be due to azotcmia. Parenchymal lesions were seen primarily at the insistence of anxious parents who desired consultation with a "kidney specialist." A.11 were referred to pedia tricrnns. The miscellaneous group (table 7) includes various lesions not seen frequently enough to be significant. Only one child, a girl, aged 13, had symptoms and cystoscopic findings suggestive of interstitial cystitis as seen in adults. The bladder neck syndrome in female children represents 1146 patients or 47.6 per cent of the entire series. If only by virtue of its occurrence this entity assumes great importance in pediatric urology. Furthermore, there is sound basis for the thesis that bladder neck disease in childhood
The pediatric,1 medical, 2 • 3 and urological literature in recent years has documented the importance of thorough investigation and definitive management of genitourinary problems in children. Therefore, the pediatric patient has assumed greater importance in urological practice in the last decade. The material in our series, comprising 781 male and 1622 fernale children, represents a 10 year period: ,January 1951 to January 1961. Age range is birth to (not including) 15 years. Examination of these children as outpatients presumes the usual facilities plus recovery beds, suction and other requirements for meeting anesthetic emergencies. However, with trichloroethylene (trilene) the facility with which this is done is renmrkable. Prernedication with nembutal, demerol and scopolamine plus trilene inhalation provides safe, effective analgesia and in1mobility with rapid recovery and little postanesthetic morbidity. This is used exclusively save in male children where deeper anesthesia is required for cystourethroscopy. ,Ve have encountered no serious ancstbctic difficulties with trilene. Infections comprised 1417 or 59 per cent of the entire series and anomalies 578 or 22.2 per cent. Infections occurred primarily in female children. The bladder neck syndrome in female children is included in the tabulation of cases of infecti011 for reasons subsequently noted. Cases diagnosrd as urinary infection per se include those that had no apparent bladder neck disease, either inflammatory or obstructive. Included in the diagnosis of pyelonephritis arc only those cases with unequivocal pyelographic changes without other contributory factors such as obstruction, anomaly Accepted for publication April 25, 1961. Read a,t annual meeting of Southeastern Section, American Urological Association, Inc., Hollywood, Fla., March 19-24, 1961. 1 Michie, A . .J.: Pediatric urology: Summary of round table. PediRtrics, 24: 1118-1122, 1959. 2 Wlrnrton, L. R., Gray, L. A. and Guild, H. G.: Late effects of acute pyelitis in girls, J. A. M. A., 109: 1597-1602, 1937.
3 St raff on, R. A. and Engel, W. J.: Diagnosis and treatment of urinary tract infection in children . .T. A. M.A., 174: 1377--1381, 1960.
68
PEDIATRIC UROLOGY
TABLE 1. Infections
TABLE 3. Anomalies: Kidney, ureter and bladder
Number
Bladder neck syndrome (females) (contracture, urethrotrigonitis). Urinary tract infection. Acute hemorrhagic cystitis Verumontanitis. Pyelonephri tis .... Epididymitis ... Tuberculous pyelonephritis. .. Adhesive vulvitis. Posterior urethral polyps (male). Prostatitis Perinephric abscess.
1196 117
44 22 12 6 5 5
84.4 8.3 3.1 1.6 .8 .4 .4 .4
5 3
.4 .2 .1
2
- - - - - - - - - - - - - - ~ - -- - - - - -
Total.
1417
Number
%
59
TABLE 2. Anomalies Number
%
71 73 5 98 73 257 1
2.9 3.0 .2 4.1 3.0 10.7 .04
578
22.2
Kidney Ureteropelvic obstruction (congenital hydronephrosis) . Solitary kidney. Hypoplastic kidney. Ectopic kidney. Hydrocalyx . Pol ycystic disease .. IVIulticystic kidney . Horseshoe kidney . Total. Ureter Ureterovesical or low ureteral obstruction (hydronephrosis and hydro ureter) .... Ureterocele .. Ureteral ectopic orifice .. Reduplication anomaly. Total.
Kidney .. Ureter. Bladder. Scrotal contents . Penis. Urethra and bladder neck. Hermaphroditism. Total ..
is the precursor of chronic urinary tract infirmity3 in adult life with resultant renal damage due to chronic pyelonephritis. 2 • 4 • 5 The literature is replete with this allegation and the incidence of chronic pyelonephritis is reported as 10-20 per cent at autopsy. 6 Therefore, urologists cannot reconcile a passive attitude toward an entity which may jeopardize future health and life. We include in this group all female children with inflammatory and/or obstructive phenomena in the urethra or at the bladder neck. We be4 J awetz, E.: Urinary Tract Infections, Disease of the Month. Chicago: Year Book Publishers,
1954, pp. 1-31.
5 Woodruff, J. D. and Everett, H. S.: Prognosis in childhood urinary tract infections in girls (Holmes lecture). Am. J. Obst. & Gynec. 68:
798-809, 1954.
'
Colby, F. H.: Pyelonephritis. Baltimore: The Williams and Wilkins Co., 1959. 6
Bladder Exstrophy. Triogonal curtain .. Total.
37 JO 8 6
4 3
1 2
71
23 11 4
45 83
4
l 5
lieve, as do McDonald 7 and Straffron and Engel, 3 and others that it is most difficult to unequivocally separate obstructive and inflammatorv lesions of the bladder neck. Undoubtedly they exist concurrently in many young patients. Which is primary is enigmatical at best. There are many which present unmistakable evidence of obstruction by virtue of residual urine, trabeculation of the bladder, restricted vesical outlet, and possibly vesicoureteral reflux. The subtle degrees of obstruction versus inflammation are perplexing and exact decision frequently leaves the urologist in a dilemma. ,Yhile every effort is made to differentiate these lesions it is, finally, the overall response of the patient which is important. Except for those who have initial obstruction of some magnitude, our primary approach to the two entities is virtually identical: conservative management. 7 McDonald, H. P., Upchurch, W. E. and Sturdevant, C. E.: Vesical neck obstructions in children. J. Urol., 70: 92-97, 1953.
70
TUDOR, CARTER, JVIcCLELLE~ AND NESBITT
TABLE
4. Anomalies: Genitalia, bladder neck (male)
urethra and
Number
TABLE
6. Calculous disease, endocrine disorders ancl parenchymal lesions
Number
Number
---------------1----~---
Scrotal contents Cryptorchism .. Unilateral.. Bilateral. Hydrocele Tunica vaginalis Cord. Torsion. Testicle Appendix testicle. V aricocele .. Agenesis (unilateral) ..
48 39 9 32 29 3 1G
15 1 1 1
Calculous disease Renal .... Ureteral.
12 4
Total.
16
Endocrine disorders Diabetes mellitus. Diabetes insipidus Hypogonadism. Parathyroid adenorna. Total.
Penis. Hypospadias (all degrees). Epispadias.
69
4
1 13
Parenchymal lesions Glomerulonephritis Kephrosis
,59 6
4
Total ..
65
73
Total.
TABLE
Urethra and bladder neck (male) Meatal stricture .. Bladder neck obstruction (bar, valves, contracture). "Grethral stricture Balanitis xerotica obliterans.
54 31 6
5. 1Veoplasins ancl trauma
Neoplasms Wilms tumor. Sarcoma (bladder) .. Total. Trauma Genital trauma. Vesical and/ or urethral. Renal trauma. Vesicovaginal fistula ..
7. 1vliscellaneo1lS
166
Number
Total.
1
98
Total.
TABLE
7
9
1 10
15 4 14 1 34
It is in this group of patients that the nebulous "will of the wisp" vesicoureteral reflux oecasionally presents itself to further eonfuse the picture and eompound the management. J\foch
Number
Acute abdomen. Blood dyscrasia. Bartholin cyst Urethral eversion. Genital condylomata .. Interstitial cystitis. Urethral prolapse. Total ..
4 2
1 1 2
1 3 14
has been written on this issue by Hutch, 8 Stewart, 9 Lattimer10 t1nd many others. Various surgical methods have been devised to prevent reflux.11- 12 In our opinion the exact significance, etiology, and precise management of reflux are, 8 Hutch, J. A., Bunge, R. G. and Flocks, R.: Vesicoureteral reflux in children . .J. Frol., 74: 607-620, 1955. 9 Stewart, C. M.: Delayed cystograms. J. Urol., 70: 588-592, 1953. 10 Leuzinger, D. E., Lattimer, .J. K. and McCoy, C. B.: Reflux is dangerous but not always disastrous: Conservative treatment often effective . .J. Urol., 82: 294-303, 1959. 11 Paquin, A . .J., Jr.: Ureterovesical anastomosis: Description and evaluation of technique . .J. Urol., 82: 573-583, 1959. 12 Politano, V. A. and Lea,dbetter, W. F.: Operative technique for correction of vesicoureteral reflux . .J. Urol., 79: 932-941, 1958.
71
PEDIATRIC UROLOGY
as yet, undetermined. Undoubtedly, both inflammatory and obstructive elements play some role in production and maintenance of reflux. Our surgical philosophy is conservative. Only those cases of persistent reflux, with progressive upper tract damage or recurrent uncontrolled infection due to reflux, are attacked surgically. Reflux per se or persistent reflux without infection and upper tract damage does not constitute an indication for vesicoureteral revision. We have on occasion seen the apparent reversal or disappearance of reflux under conservative management. Recently, the method of Politano 12 has been used in virtually all of the patients who have come to ureterovesical revision. We hold the same attitude in regard to bladder neck obstruction in the female child. Treatment of the vast majority is conservative. Again, only those who have recurring uncontrollable infections, upper tract damage, either due to TABLE
8. Age incidence: Bladder neck syndrome (female)
obstruction or concurrent pyelonephritis, and the rare patient with intractable symptoms are considered surgically, Surgical intervention in both instances almost always presumes failure of conservative management. Perhaps one should consider seriously the maxim that one is dealing with patients rather than with reflux-trabeculation-residual urine. Again, we have observed, as have most urologists, the reversal of reflux and obstruction at the bladder neck when an effective, well managed, conservative program is instituted. One or more and, occasionally, all of the following procedures are used in conservative care of bladder neck disease: periodic calibration and dilatation, multiple voiding techniques, antimicrobial- and chemotherapy, vulvar hygiene, periodic evaluation of renal functions and pyelography for surveillance of upper tract deterioration. The administration of antimicrobial and chemotherapeutic drugs is carried out over a long period of time and usually on an interrupted TABLE
Age in yrs.
Number
0-2 3-6 7-10 Over 10
253 653 240 50
Total ..
%
22.0 57.0 20.9 4.4
1146
In this series the most common age incidence was from 3 to 6 yrs., 57 per cent of the group falling in this range. TABLE
and residual urine Number
Upper tract findings Normal. Abnormal* .. Refluxt ... Residual urine No determinations. Patients with 30 cc or more.
I
%
909 90 30
76.0 7.5 2.5
238
9.9
61
2.5
9. Results of urinalysis and culture Number
Urinalysis Pyuria 0. 1.
2. 3. 4.
Cultures Negative. Positive. Gram-negative .. Gram-positive .. Mixed.
%
* Normal duplication anomalies not included. t 291 patients had cystograms. TABLE
218 612 115 49 137
-------------- ----'-
10. Upper tract findings, reflux
561 559 371 129 59
18.2 51.2 9.6 4.1 11.5 -----
46.9 46.7 31.1 10.8 4.9
11. Treatment: Bladder neck syndrome Number
Conservative. Surgical. Endoscopic ... Bladder neck posterior Y -V. Ureterovesical revision Not treated.
1046 56 34 12 10 94
%
87.5 4.7 2.8 1.0 .8 7.9
---------------------------
Total.
104.7*
* More than one type surgical procedure or conservative-surgical.
72
TUDOR, CARTER, McCLELLEN AND XESBITT
schedule. Initially the patient is given a vigorous therapeutic course of one of the antimicrobials. "\Vhen the infection has responded, the patient is kept on an interrupted schedule with increasing intervals between each administration of the selected drug. On this interrupted schedule the drug is prescribed in adequate therapeutic amounts and for therapeutic duration. J'vfany patients are on medication for a year or more, and urinalyses plus cultures and sensitivity studies are obtained at frequent intervals initially and every 2-3 months later in the course of the treatment. Summarily, the cardinal aspects of successful conservatism are adequate local treatment, prolonged chemotherapy and persistent followup studies. It is not our intent to overstate the cause of conservatism. One should not remain surgically idle and allow deterioration or irreparable damage to the upper urinary tract to ensue due either to obstructive or inflammatory disease of the bladder neck. Ho\vever, it is our firm conviction, based on experience in this series, that the vast majority of these children do not require either surgical revision of the bladder neck or ureteral reimplantation. This holds for those with varying degrees of unequivocal bladder neck obstruction as well as those who apparently have only inflammatory disease. Detailed descriptions of procedures and results are to be included in a subsequent report. Tables 8-11 are of interest in terms of a general analysis of the problem of bladder neck disease in tl1e female child. Delayed cystograms are not mutine procedures. These patients with recurring infection whose
pyelograms or cystoscopic findings indicate definite obstruction or patulous ureteral orificrs are subjected to delayed cystography. A large number of patients, particularly those seen early in the series, did not undergo cystography. The importance accorded vesicoureteral reflux in the recent literature has stimulated our interest in this phenomenon, but has not changed our impression regarding management of the prohlem. Reflux can neither be proven nor disproven on the basis of one examination and patients exhibiting poor clinical response or failure of conservative treatment require multiple examinations. It will be noted in table 11 tbat conservative treatment was instituted in 87.5 per cent of these patients, surgical treatment in 4.7 per cent. Endoscopic surgery or transurethral electroresection plu~ fulguration of the bladder neck has been virtually abandoned. l\Iost of the transurethral procedures were carried out in the early cases and the results did not justify continuance. CONCLUSIONS
Analysis of 2403 pediatric consultations is presented and the occurrence of various lesions is noted. General aspects of the bladder neck syndrome in female children arc tabulated. The importance of thorough investigation and adequate treatment is stressed. Conservative management of inflammatory and/or obstructive lesions in the bladder neck in female children is emphasized. 192.1 Hayes St., Nashville ,f, Tenn.
Vol. 87, No. 1 January 1962 Copyright © 1962 by The Williams & Wilkins Co. Printed in U.S.A.
AN ANALYSIS OF 2403 CONSECUTIVE PEDIATRIC UROLOGICAL CONSULTATIONS JOHN M. TUDOR, OSCAR W. CARTER, ROBERT E. McCLELLEN
AND
TOM E. NESBITT
or calculus. Therefore, chronic pyelonephritis may be a more appropriate diagnosis in this instance. Naturally, many of the patients in whom the diagnosis was urinary tract infection or bladder neck syndrome initially or subsequently had symptoms and signs of acute pyeloncphritis (table 1). The anomalies listed in tables 2, 3 and 4 do not include normal reduplications. The large number of urethral and bladder anomalies (table 4) includes all degrees of hypospadias. The number of cases of cryptorchism and hyclrocele (table 5) is perhaps small for this series. l\!Iany of these arc seen by general surgeons in our community. The large number ot cases of meatal stricture is again noted, the most common lesion in the male child. madder neck obstruction includes all degrees of severity from mild to those creating severe obstruction and profound upper urinary tract damage. Our series of \Vilms tumors is likewise small (tabl0 5). Many of these patients, especially those who present with an abdominal nmss, are seen by general surgeons. Genital injury runs the gamut; mild to severe, as do vesicourethral and renal trauma. The vesicovaginal fistula was a sequcla of transurethral bladder neck resection. Calculous disease is not common in children (table 6). N"o vesical stones incident to catheter or foreign body are included. Diabetes mellitus was seen in 2 conneetions; polyuria, and coma thought to be due to azotcmia. Parenchymal lesions were seen primarily at the insistence of anxious parents who desired consultation with a "kidney specialist." A.11 were referred to pedia tricrnns. The miscellaneous group (table 7) includes various lesions not seen frequently enough to be significant. Only one child, a girl, aged 13, had symptoms and cystoscopic findings suggestive of interstitial cystitis as seen in adults. The bladder neck syndrome in female children represents 1146 patients or 47.6 per cent of the entire series. If only by virtue of its occurrence this entity assumes great importance in pediatric urology. Furthermore, there is sound basis for the thesis that bladder neck disease in childhood
The pediatric,1 medical, 2 • 3 and urological literature in recent years has documented the importance of thorough investigation and definitive management of genitourinary problems in children. Therefore, the pediatric patient has assumed greater importance in urological practice in the last decade. The material in our series, comprising 781 male and 1622 fernale children, represents a 10 year period: ,January 1951 to January 1961. Age range is birth to (not including) 15 years. Examination of these children as outpatients presumes the usual facilities plus recovery beds, suction and other requirements for meeting anesthetic emergencies. However, with trichloroethylene (trilene) the facility with which this is done is renmrkable. Prernedication with nembutal, demerol and scopolamine plus trilene inhalation provides safe, effective analgesia and in1mobility with rapid recovery and little postanesthetic morbidity. This is used exclusively save in male children where deeper anesthesia is required for cystourethroscopy. ,Ve have encountered no serious ancstbctic difficulties with trilene. Infections comprised 1417 or 59 per cent of the entire series and anomalies 578 or 22.2 per cent. Infections occurred primarily in female children. The bladder neck syndrome in female children is included in the tabulation of cases of infecti011 for reasons subsequently noted. Cases diagnosrd as urinary infection per se include those that had no apparent bladder neck disease, either inflammatory or obstructive. Included in the diagnosis of pyelonephritis arc only those cases with unequivocal pyelographic changes without other contributory factors such as obstruction, anomaly Accepted for publication April 25, 1961. Read a,t annual meeting of Southeastern Section, American Urological Association, Inc., Hollywood, Fla., March 19-24, 1961. 1 Michie, A . .J.: Pediatric urology: Summary of round table. PediRtrics, 24: 1118-1122, 1959. 2 Wlrnrton, L. R., Gray, L. A. and Guild, H. G.: Late effects of acute pyelitis in girls, J. A. M. A., 109: 1597-1602, 1937.
3 St raff on, R. A. and Engel, W. J.: Diagnosis and treatment of urinary tract infection in children . .T. A. M.A., 174: 1377--1381, 1960.
68
PEDIATRIC UROLOGY
TABLE 1. Infections
TABLE 3. Anomalies: Kidney, ureter and bladder
Number
Bladder neck syndrome (females) (contracture, urethrotrigonitis). Urinary tract infection. Acute hemorrhagic cystitis Verumontanitis. Pyelonephri tis .... Epididymitis ... Tuberculous pyelonephritis. .. Adhesive vulvitis. Posterior urethral polyps (male). Prostatitis Perinephric abscess.
1196 117
44 22 12 6 5 5
84.4 8.3 3.1 1.6 .8 .4 .4 .4
5 3
.4 .2 .1
2
- - - - - - - - - - - - - - ~ - -- - - - - -
Total.
1417
Number
%
59
TABLE 2. Anomalies Number
%
71 73 5 98 73 257 1
2.9 3.0 .2 4.1 3.0 10.7 .04
578
22.2
Kidney Ureteropelvic obstruction (congenital hydronephrosis) . Solitary kidney. Hypoplastic kidney. Ectopic kidney. Hydrocalyx . Pol ycystic disease .. IVIulticystic kidney . Horseshoe kidney . Total. Ureter Ureterovesical or low ureteral obstruction (hydronephrosis and hydro ureter) .... Ureterocele .. Ureteral ectopic orifice .. Reduplication anomaly. Total.
Kidney .. Ureter. Bladder. Scrotal contents . Penis. Urethra and bladder neck. Hermaphroditism. Total ..
is the precursor of chronic urinary tract infirmity3 in adult life with resultant renal damage due to chronic pyelonephritis. 2 • 4 • 5 The literature is replete with this allegation and the incidence of chronic pyelonephritis is reported as 10-20 per cent at autopsy. 6 Therefore, urologists cannot reconcile a passive attitude toward an entity which may jeopardize future health and life. We include in this group all female children with inflammatory and/or obstructive phenomena in the urethra or at the bladder neck. We be4 J awetz, E.: Urinary Tract Infections, Disease of the Month. Chicago: Year Book Publishers,
1954, pp. 1-31.
5 Woodruff, J. D. and Everett, H. S.: Prognosis in childhood urinary tract infections in girls (Holmes lecture). Am. J. Obst. & Gynec. 68:
798-809, 1954.
'
Colby, F. H.: Pyelonephritis. Baltimore: The Williams and Wilkins Co., 1959. 6
Bladder Exstrophy. Triogonal curtain .. Total.
37 JO 8 6
4 3
1 2
71
23 11 4
45 83
4
l 5
lieve, as do McDonald 7 and Straffron and Engel, 3 and others that it is most difficult to unequivocally separate obstructive and inflammatorv lesions of the bladder neck. Undoubtedly they exist concurrently in many young patients. Which is primary is enigmatical at best. There are many which present unmistakable evidence of obstruction by virtue of residual urine, trabeculation of the bladder, restricted vesical outlet, and possibly vesicoureteral reflux. The subtle degrees of obstruction versus inflammation are perplexing and exact decision frequently leaves the urologist in a dilemma. ,Yhile every effort is made to differentiate these lesions it is, finally, the overall response of the patient which is important. Except for those who have initial obstruction of some magnitude, our primary approach to the two entities is virtually identical: conservative management. 7 McDonald, H. P., Upchurch, W. E. and Sturdevant, C. E.: Vesical neck obstructions in children. J. Urol., 70: 92-97, 1953.
70
TUDOR, CARTER, JVIcCLELLE~ AND NESBITT
TABLE
4. Anomalies: Genitalia, bladder neck (male)
urethra and
Number
TABLE
6. Calculous disease, endocrine disorders ancl parenchymal lesions
Number
Number
---------------1----~---
Scrotal contents Cryptorchism .. Unilateral.. Bilateral. Hydrocele Tunica vaginalis Cord. Torsion. Testicle Appendix testicle. V aricocele .. Agenesis (unilateral) ..
48 39 9 32 29 3 1G
15 1 1 1
Calculous disease Renal .... Ureteral.
12 4
Total.
16
Endocrine disorders Diabetes mellitus. Diabetes insipidus Hypogonadism. Parathyroid adenorna. Total.
Penis. Hypospadias (all degrees). Epispadias.
69
4
1 13
Parenchymal lesions Glomerulonephritis Kephrosis
,59 6
4
Total ..
65
73
Total.
TABLE
Urethra and bladder neck (male) Meatal stricture .. Bladder neck obstruction (bar, valves, contracture). "Grethral stricture Balanitis xerotica obliterans.
54 31 6
5. 1Veoplasins ancl trauma
Neoplasms Wilms tumor. Sarcoma (bladder) .. Total. Trauma Genital trauma. Vesical and/ or urethral. Renal trauma. Vesicovaginal fistula ..
7. 1vliscellaneo1lS
166
Number
Total.
1
98
Total.
TABLE
7
9
1 10
15 4 14 1 34
It is in this group of patients that the nebulous "will of the wisp" vesicoureteral reflux oecasionally presents itself to further eonfuse the picture and eompound the management. J\foch
Number
Acute abdomen. Blood dyscrasia. Bartholin cyst Urethral eversion. Genital condylomata .. Interstitial cystitis. Urethral prolapse. Total ..
4 2
1 1 2
1 3 14
has been written on this issue by Hutch, 8 Stewart, 9 Lattimer10 t1nd many others. Various surgical methods have been devised to prevent reflux.11- 12 In our opinion the exact significance, etiology, and precise management of reflux are, 8 Hutch, J. A., Bunge, R. G. and Flocks, R.: Vesicoureteral reflux in children . .J. Frol., 74: 607-620, 1955. 9 Stewart, C. M.: Delayed cystograms. J. Urol., 70: 588-592, 1953. 10 Leuzinger, D. E., Lattimer, .J. K. and McCoy, C. B.: Reflux is dangerous but not always disastrous: Conservative treatment often effective . .J. Urol., 82: 294-303, 1959. 11 Paquin, A . .J., Jr.: Ureterovesical anastomosis: Description and evaluation of technique . .J. Urol., 82: 573-583, 1959. 12 Politano, V. A. and Lea,dbetter, W. F.: Operative technique for correction of vesicoureteral reflux . .J. Urol., 79: 932-941, 1958.
71
PEDIATRIC UROLOGY
as yet, undetermined. Undoubtedly, both inflammatory and obstructive elements play some role in production and maintenance of reflux. Our surgical philosophy is conservative. Only those cases of persistent reflux, with progressive upper tract damage or recurrent uncontrolled infection due to reflux, are attacked surgically. Reflux per se or persistent reflux without infection and upper tract damage does not constitute an indication for vesicoureteral revision. We have on occasion seen the apparent reversal or disappearance of reflux under conservative management. Recently, the method of Politano 12 has been used in virtually all of the patients who have come to ureterovesical revision. We hold the same attitude in regard to bladder neck obstruction in the female child. Treatment of the vast majority is conservative. Again, only those who have recurring uncontrollable infections, upper tract damage, either due to TABLE
8. Age incidence: Bladder neck syndrome (female)
obstruction or concurrent pyelonephritis, and the rare patient with intractable symptoms are considered surgically, Surgical intervention in both instances almost always presumes failure of conservative management. Perhaps one should consider seriously the maxim that one is dealing with patients rather than with reflux-trabeculation-residual urine. Again, we have observed, as have most urologists, the reversal of reflux and obstruction at the bladder neck when an effective, well managed, conservative program is instituted. One or more and, occasionally, all of the following procedures are used in conservative care of bladder neck disease: periodic calibration and dilatation, multiple voiding techniques, antimicrobial- and chemotherapy, vulvar hygiene, periodic evaluation of renal functions and pyelography for surveillance of upper tract deterioration. The administration of antimicrobial and chemotherapeutic drugs is carried out over a long period of time and usually on an interrupted TABLE
Age in yrs.
Number
0-2 3-6 7-10 Over 10
253 653 240 50
Total ..
%
22.0 57.0 20.9 4.4
1146
In this series the most common age incidence was from 3 to 6 yrs., 57 per cent of the group falling in this range. TABLE
and residual urine Number
Upper tract findings Normal. Abnormal* .. Refluxt ... Residual urine No determinations. Patients with 30 cc or more.
I
%
909 90 30
76.0 7.5 2.5
238
9.9
61
2.5
9. Results of urinalysis and culture Number
Urinalysis Pyuria 0. 1.
2. 3. 4.
Cultures Negative. Positive. Gram-negative .. Gram-positive .. Mixed.
%
* Normal duplication anomalies not included. t 291 patients had cystograms. TABLE
218 612 115 49 137
-------------- ----'-
10. Upper tract findings, reflux
561 559 371 129 59
18.2 51.2 9.6 4.1 11.5 -----
46.9 46.7 31.1 10.8 4.9
11. Treatment: Bladder neck syndrome Number
Conservative. Surgical. Endoscopic ... Bladder neck posterior Y -V. Ureterovesical revision Not treated.
1046 56 34 12 10 94
%
87.5 4.7 2.8 1.0 .8 7.9
---------------------------
Total.
104.7*
* More than one type surgical procedure or conservative-surgical.
72
TUDOR, CARTER, McCLELLEN AND XESBITT
schedule. Initially the patient is given a vigorous therapeutic course of one of the antimicrobials. "\Vhen the infection has responded, the patient is kept on an interrupted schedule with increasing intervals between each administration of the selected drug. On this interrupted schedule the drug is prescribed in adequate therapeutic amounts and for therapeutic duration. J'vfany patients are on medication for a year or more, and urinalyses plus cultures and sensitivity studies are obtained at frequent intervals initially and every 2-3 months later in the course of the treatment. Summarily, the cardinal aspects of successful conservatism are adequate local treatment, prolonged chemotherapy and persistent followup studies. It is not our intent to overstate the cause of conservatism. One should not remain surgically idle and allow deterioration or irreparable damage to the upper urinary tract to ensue due either to obstructive or inflammatory disease of the bladder neck. Ho\vever, it is our firm conviction, based on experience in this series, that the vast majority of these children do not require either surgical revision of the bladder neck or ureteral reimplantation. This holds for those with varying degrees of unequivocal bladder neck obstruction as well as those who apparently have only inflammatory disease. Detailed descriptions of procedures and results are to be included in a subsequent report. Tables 8-11 are of interest in terms of a general analysis of the problem of bladder neck disease in tl1e female child. Delayed cystograms are not mutine procedures. These patients with recurring infection whose
pyelograms or cystoscopic findings indicate definite obstruction or patulous ureteral orificrs are subjected to delayed cystography. A large number of patients, particularly those seen early in the series, did not undergo cystography. The importance accorded vesicoureteral reflux in the recent literature has stimulated our interest in this phenomenon, but has not changed our impression regarding management of the prohlem. Reflux can neither be proven nor disproven on the basis of one examination and patients exhibiting poor clinical response or failure of conservative treatment require multiple examinations. It will be noted in table 11 tbat conservative treatment was instituted in 87.5 per cent of these patients, surgical treatment in 4.7 per cent. Endoscopic surgery or transurethral electroresection plu~ fulguration of the bladder neck has been virtually abandoned. l\Iost of the transurethral procedures were carried out in the early cases and the results did not justify continuance. CONCLUSIONS
Analysis of 2403 pediatric consultations is presented and the occurrence of various lesions is noted. General aspects of the bladder neck syndrome in female children arc tabulated. The importance of thorough investigation and adequate treatment is stressed. Conservative management of inflammatory and/or obstructive lesions in the bladder neck in female children is emphasized. 192.1 Hayes St., Nashville ,f, Tenn.