Pediatric Urology and Congenital Anomalies
Core concepts
Paediatric urology is largely embryology applied to a clinical presentation, so learn the embryological origin of each anomaly.
Antenatal hydronephrosis: know the grading (SFU), the significance of a ureteric dilatation versus isolated pelvic dilatation, and that most mild antenatal hydronephrosis resolves. Trap: intervening on antenatal hydronephrosis without postnatal confirmation and functional assessment.
Vesicoureteric reflux: grades I-V; management is antibiotic prophylaxis in selected cases, and surgery for breakthrough infections or high-grade reflux with scarring.
Posterior urethral valves: the commonest cause of lower urinary tract obstruction in boys; presents with poor stream, palpable bladder, and bilateral hydronephrosis; confirmed on micturating cystourethrogram; treated by valve ablation, with lifelong follow-up for bladder dysfunction and renal failure.
Undescended testis: know the timing of orchidopexy (within the first year, ideally by 12-18 months) and the malignancy and fertility implications.
Hypospadias: do not circumcise; the prepuce is needed for reconstruction.
Others: testicular torsion, hydrocele, inguinal hernia, duplex systems, ureterocoele, prune belly, and disorders of sex development.
Worked rule of thumb
A newborn boy with bilateral hydronephrosis, a thick-walled bladder and a poor stream: think posterior urethral valves - the trap answer is "reflux", which would not explain the thick-walled bladder and poor stream in a male neonate.
Exam traps
- Circumcising a boy with hypospadias.
- Delaying orchidopexy beyond the recommended window.
- Missing posterior urethral valves in a male neonate with bilateral hydronephrosis.
- Treating antenatal hydronephrosis without postnatal confirmation.