Paediatric Circumcision
Undescended Testes
Paediatric Urinary Tract Infections
Congenital Urological Problems
Paediatric Hydrocoele
Paediatric Circumcision
Circumcision is the name given to the surgical procedure where the foreskin of the penis is removed. Circumcision is often done for religious reasons, as part of family or cultural traditions, and for personal hygiene or preventative health reasons. Medical circumcision is often performed for phimosis: a condition where the foreskin is too tight and not able to retract.
Before the circumcision
You will see the urologist for a consultation before the procedure, where your doctor will explain the risks, benefits and potential complications as well as the expected post-operative course. You will also be expected to provide written consent before the surgery can be conducted.
On the day of the operation
Most procedures are performed as a day case under anaesthesia. You will need to obtain authorisation from your Medical Aid/Insurance before the procedure. Please ask for a cost estimate from our rooms. Your child will have a short anaesthetic, and will therefore need to be starved for 6 hours before the scheduled surgery. They may drink clear fluids only (such as water or diluted clear apple juice) until 2 hours before surgery.
After the circumcision
After the circumcision, you will receive detailed instructions on how to care for your child’s wound. Typically, a circumcision takes approximately four to seven days to heal. You may bath/wash your baby two days after the procedure. The doctor will also instruct you to apply antibacterial ointment and petroleum jelly (Vaseline) to the wound on a regular basis, in the case of babies with every nappy change.
It is usual to notice a small amount of blood on your baby’s diaper or after you remove the dressing. Slight blood is not a cause for concern and will eventually resolve on its own. There may be bruising or swelling of the skin of the penis, which take longer than a few days to resolve. Where the foreskin was stuck to the glans penis, a soft brown scab may form. This must not be removed as the skin is healing underneath. Simply wash the penis in the bath, and apply ointment/Vaseline regularly to keep it moist.
Generally, your baby’s penis will be a little painful for the first day or two after the circumcision, and it is important to give some pain medicine regularly.
Complications
Bleeding is the most common complication following circumcision. We take the utmost care to stop all bleeding in theatre, but rarely, we need to return to theatre if the bleeding does not stop. If you are concerned, call the doctor or visit the nearest emergency room.
When the circumcision wound re-attaches to the glans penis (which may have a raw area) skin bridges can form. This can be avoided by pulling back the penis skin properly before applying ointment to the sutures.
Although rare, sometimes you may not be entirely satisfied with the cosmetic appearance after the surgery. You may feel that the foreskin has been cut too long or too short. Ensure you fully discuss your expectations with your surgeon before the operation.
Undescended Testes
An undescended testicle (also known as cryptorchidism) is a condition where the testicle has failed to reach its correct location in the scrotum. This is more common in premature babies. Often only one testicle is undescended, but in few cases, both the testes can be undescended.
Symptoms
There are no symptoms, as an undescended testicle is not painful for the child. The main finding on physical examination is the inability to palpate both testicles in the scrotum.
Screening for and investigating undescended testes
If, after birth, your doctor or paediatrician has not found a testicle in the scrotum of your son, then you will be referred to a paediatric urologist.
Treatment options for undescended testes
Your urologist will usually recommend surgery to treat this condition. The surgery can be conducted in two ways:
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Laparoscopically: Your urologist makes tiny (keyhole) incisions in the abdomen of your son to insert a laparoscope, which will locate an intra-abdominal testicle. Your doctor might be able to correct the undescended testicle or testes during that same procedure, or your son might require more than one operation, called a staged procedure.
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Open surgery: A small incision is made in the groin of your son to explore the groin and find the undescended testicle, which is then brought into the scrotum where it is fixed.
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Paediatrics Urinary Tract Infections
Urinary tract infections (UTIs) are a common cause of fever in infants and young children. They occur when bacteria enter and multiply in the urinary tract.
Risk factors
Urinary tract infections occur more often in girls, especially when they start toilet training. Girls are more susceptible due to their urethras being shorter and closer to the vagina and anus, which then makes it easy for bacteria to enter.
Uncircumcised young boys may also slightly be at a higher risk of getting UTIs if the foreskin does not easily retract.
The following factors increase the risk of urinary tract infections in children:
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Structural deformity or blockage of one of the urinary tract organs.
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Abnormal functioning of the urinary tract.
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Vesicoureteral reflux of urine, which results in the abnormal backward flow of urine from the bladder to the kidneys.
Symptoms
Signs and symptoms of urinary tract infections in children include:
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Pain, stinging or burning sensation while urinating.
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Urinary frequency and urge to urinate with minimal urine output.
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Urine accidents (occurring after child has potty trained).
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Cloudy and smelly urine.
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Blood in the urine.
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Fever.
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Poor appetite, vomiting and /or diarrhoea.
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Pain in the lower abdomen or back.
Investigating and treating a urinary tract infection
Seek medical help if your child is experiencing urinary tract infection symptoms. The GP/paediatrician may conduct the following tests to make an accurate diagnosis:
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Urinalysis: This is a urine test to check for infection, bacteria or pus. This should be followed by a urine culture, which involves sending the urine sample to a laboratory to identify the bacteria that might be causing the urinary tract infection. This way doctors can definitively “document” whether or not your child has an infection.
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Imaging of the urinary tract: An ultrasound of the kidneys and bladder is usually adequate to investigate a urinary tract infection and should be done in all children with a documented UTI.
Urinary tract infection treatment options
Urinary tract infections are normally treated with antibiotics. However, the way in which your child receives the antibiotics depends entirely on the type and severity of the infection. Further investigation may be needed to find the cause of the infections. Sometimes, corrective surgery is needed to resolve the problem.
Congenital Urological Problems
Congenital urological abnormalities are birth defects, which occur during fetal development, usually very early during a pregnancy. These can affect different parts of the genitourinary system and sometimes other organs too.
There are different types of congenital urological problems, such as:
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Antenatal Hydronephrosis – this is a common condition where there is too much fluid seen in one or both the kidneys, on ultrasound done during pregnancy. This may sometimes be due to an obstruction somewhere between the bladder and the kidneys. If your obstetrician is concerned, you will be referred to a paediatric urologist after birth of your child.
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Vesicoureteric reflux (VUR) – also known as urinary reflux. This is a condition where there is a backflow of urine from the bladder to the kidneys. This can cause problems with urinary tract infections and sometimes with kidney development. Your paediatrician will often refer your child to a paediatric urologist for an assessment.
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Renal Agenesis – this is a condition where one kidney did not develop properly and your child only has one kidney. Many people function completely normally and lead completely normal lives with a single kidney.
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Renal hypoplasia – this is a condition where one or both the kidneys are abnormally small, often due to some insult to the kidney during its early development. A very small kidney may not function very well.
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Duplex ureters (or duplicated ureters) - this is a relatively common condition where there are two instead of one ureter between the kidney and the bladder. This can be a normal variant, but sometimes causes problems.
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Posterior urethral valves – this is a rare condition where there is an obstruction to the outflow of urine from the bladder. This happens during the development of the baby, during the pregnancy, and usually needs treatment shortly after birth.
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Hypospadias - this is a condition where the urethra in boys did not quite develop completely and therefore did not reach the tip of the penis. The urethra opens somewhere along the underside of the penis. It is usually associated with an abnormal looking foreskin and a curved penis, called chordee.
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Megaureter - an uncommon condition where one or both ureters appear very dilated on scans. Mostly these abnormal looking ureters still work and the child seldom needs an operation
Paediatrics Hydrocoele
A hydrocoele occurs when the scrotum swells due to an accumulation of fluid in the layers that surround the testicle.
Risk factors
A hydrocele is common in new-born babies, and is found in up to 1 in 10 infant boys. Premature babies are often found to have hydrocoeles. The fluid often disappears without treatment in the first year of life. The cause is often related to a patent processus vaginalis, when the channel that is used by the testicle to descend into the scrotum fails to close. This open channel allows fluid to move between the abdomen and scrotum, and is also called a communicating hydrocoele or fluid hernia.
Symptoms
The main symptom of a hydrocele in infants is swelling, which is painless. Both testicles can be affected. The swelling may change in size during the course of the day. It may get bigger over time.
If there is a tender lump in or above the scrotum, or your infant develops nausea and vomiting, you should see a health care provider to exclude an intestinal hernia.
Investigating hydrocoeles
The following are tests and observations done in diagnosing a hydrocele:
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Health history the patient
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Physical examination often leads to the diagnosis
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An ultrasound of the scrotum can be useful to evaluate the testicle and scrotum.
Treatment options for a hydrocoele
Often a hydrocoele will disappear by itself, usually within the first 6 to 12 months of life. In persistent cases, a surgery called hydrocoelectomy may be needed. This is usually performed as a day procedure but requires an anaesthetic.