Bed wetting can be a real challenge in any child and impacts both the child and their entire family. Bed wetting is mostly due to a combination excess urine production at night, a smaller bladder capacity and sleep disturbance.
Here at London Children Surgery we have greater than twenty years’ experience in this condition. Frequently our new patients have seen numerous specialists in the past and are disillusioned with doctors and believe it will never get better. Your child’s bed wetting will be investigated fully in a fun and non-invasive fashion and an individual management plan for the child and the parents is produced.
FAQ’s
01. How common is bed wetting?
Bed wetting (Nocturia) is really common affecting up to 20% of 8 years and 1% of 17 years old.
02. Will they grow out of it?
Although most children do improve it can take them a very long time. The child can finding ‘waiting’ to grow out of the condition very frustrating and disempowering. Failure to seek suitable medical advice can lead to significant delays in achieving continence even after treatment starts.
03. Is family history relevant?
40% of children with bed wetting have a strong family history with a parent having had a similar history as a child.
04. When will they get better?
The length of time required to be cured is related to the length of time with the symptoms and the failure of previous medical therapy.
05. Is surgery required?
Most children do not require surgery. However, a very small number of children have a structural problem which requires investigation and surgery but it is very uncommon.
06. Is there a quick fix?
Rarely in life is there a quick fix for anything and the same applies to bed wetting. Most children require a number of visits to get them on the right path but once they are ‘fixed’ they are cured forever.
07. Why is the day time voiding pattern important?
Many children had undiagnosed major daytime issues. This is due to the affect that child void in their pattern and it is unknown to the family and parents.
08. Should I be lifting my child at night?
‘Lifting’ can stop the bed getting wet however unless the child is awake it rarely improves the situation in the long-term.
09. Should I stop them Drinking?
Lots of children don’t drink enough fluid in the day and fluid restriction is not the way to go.
10. Use of alarm?
The alarm can function very well in some children and are a very useful treatment modality in primary care.
11. Will my child need medication?
Our policy is to try and avoid medication and most children not need medication. However medication can be useful and necessary in selected children and we will always do the best for your child.
12. My child is travelling/ having a sleep over soon, what can I do?
Seeking advice is always the best first step and we are here to help. Occasionally medication is useful for an acute event in order to help a child over a worrying few days.
When we think about Incontinence, this is really day time wetting. This can be awfully embarrassing for the child, these accidents occur in school, on their way home from school or even on the way out of the cinema. This can also be a really stressful time for the parents who have frequently gone to many medical practitioners and they feel very concerned and worried that little or no progress is being made.
Here at London Children Surgery, our focus is ensuring your child has the absolute best chance of becoming dry in the day time. We have a well proven track record of investigating and explaining the causes of your child’s accidents. Your child will fully understand what’s going on and be able to help themselves get better. The vast majority of children require little medication. If medication is required, it will be the right medication for your child and given at an appropriate dose. At the end of the day we have a motto that states we want for every child to be happy, healthy and dry. We strive for that and haven’t failed yet.
What is Incontinence?
Incontinence is the accidental or involuntary loss of urine from the bladder. Most children have developed incontinence in the day time by the age of 4. If the control of the bladder is problematic during the day, this is called day time incontinence. If this occurs at night time this is called nocturnal enuresis or bedwetting. Lost of children have a combination of both.
In reality there are two major type of day time incontinence. The first is primary, where the child has never been able to become properly dry in the day time and from the moment of toilet training onwards they have always had accidents.
The second type of incontinence is called secondary. This occurs when a child has developed continence in the day time and the night time and is dry. At some stage, for some reason, they then develop day time incontinence and start to have accidents in the day time.
In both situation the children should be investigated and supported through this difficult time.
Most children grow out of these accidents and do not require treatment. Day time incontinence is not caused by behavioural difficulties or failure of toilet training or your child being lazy. There are usually real causes to what’s going on which can be quite detrimental to your child’s wellbeing and it is very important to resolve this. The vast majority of wetting in the day time occurs because the bladder is not working properly.
What types of incontinence are there?
In reality there are two major type of day time incontinence. The first is primary, where the child has never been able to become properly dry in the day time and from the moment of toilet training onwards they have always had accidents.
The second type of incontinence is called secondary. This occurs when a child has developed continence in the day time and the night time and is dry. At some stage, for some reason, they then develop day time incontinence and start to have accidents in the day time.
In both situation the children should be investigated and supported through this difficult time.
Most children grow out of these accidents and do not require treatment. Day time incontinence is not caused by behavioural difficulties or failure of toilet training or your child being lazy. There are usually real causes to what’s going on which can be quite detrimental to your child’s wellbeing and it is very important to resolve this. The vast majority of wetting in the day time occurs because the bladder is not working properly.
How does wetting occur?
Wetting occurs in the child in the day time due to a failure of communication between the bladder and the spinal cord (which sends information from the bladder and the brain). If there is a breakdown in one part of this area, day time wetting will occur. Very frequently there is a combination of factors that have combined over time to cause the wetting to worsen. All these need to be dealt with and resolved in order to a happy, well and dry child.
What happens when we come to see you to help with my child’s incontinence?
Firstly we will take a very detailed medical history to get a clear understanding of what’s going on and hat are the likely causes of this incontinence. We will examine your child to ensure there is no obvious pathology, and we frequently arrange an ultrasound scan to ensure there is no anatomical problems. The situation will be explained in great depth and your child will get an understanding of what is required and what the plan will be. A bladder diary homework is set and a noninvasive bladder test is performed at the time of the next review in order to ensure your child is emptying their bladder and voiding as well as possible. With all this information we can help make great progress getting your child well.
How long will it take for my child to get better?
This depends on your child’s underlined diagnosis and their engagement in the process. Most children when they truly engage with wanting to get dry can make great progress. Another reason it can take a while for some children to get better, there can be delays in seeing the appropriate medical help or they have been seen by other doctors or professionals and have not been successful. When this occurs, frequently we don’t get the progress we would like to see. This is well recognised, but we work with the child in order to ensure that we can resolve these problems for them and move them forward.
Urinary tract infection can be awful for the child and very worrying for the parents. Babies and infants do not demonstrate the usual symptoms of UTIs, present with high fever and irritability and frequently are diagnosed after a number of days.
Mostly oral antibiotics are required but sometimes your child needs to be hospitalised for intravenous antibiotics. However even when your child has recovered they will still require investigation to check there is no underlying cause for the infection.
Here at London Children’s Surgery we have a sensible recognised program to investigate your child. If we can avoid a stressful test for your child we will do everything possible to do so. Our aim is to keep your child happy and healthy and to demonstrate to you what caused the infection and what we can do to prevent them occurring again.
Symptoms
In younger children it can be very difficult to determine any symptoms for urinary tract infection. In older children they can present with the more classical symptoms of urinary tract infection just as pain, high fever, fowl smelling urine, pain on voiding, frequency, rushing to the toilet and urinary incontinence.
Causes
Urinary tract infection is really common in children. The vast amount of UTI generally occurs within the bladder and a small number occur within the kidney. The most commonly found bacterium to cause infection within the bladder is Escherichia coli (E. coli).
Treatments
A vast majority of children are suitable to be treated with antibiotics, however further investigations maybe required. Investigations that are useful can be, depending on the child and the symptoms, are at least an ultrasound scan. Occasionally a bladder function assessment which is a noninvasive bladder ‘MOT,’ a DMSA scan which is a nuclear medicine test which will identify kidney scarring and occasionally a micturating cystourethrogram (MCUG) is useful for determining what the internal anatomy is like.
Investigations
Urinary tract infections can be quite problematic for children. If the infection moves the bladder to kidneys, they can cause significant damage. The child could have prolonged sickness and stay in hospital. The kidney tissue itself can be damaged and the overall function of that kidney can be reduced. The child could also become septic. Some children, when they have complex urinary anatomy, may have urinary tract symptoms or urinary tract infection and have a negative urinary test. In that situation it would be very wise to perform an ultrasound scan.
FAQ’s
01. How common is urinary tract infections?
Urinary tract infection is really common in children. The vast amount of UTI generally occurs within the bladder and a small number occur within the kidney. The most commonly found bacterium to cause infection within the bladder is Escherichia coli (E. coli).
02. Is it true girls get infections more commonly?
Girls do get more urinary tract infection than boys. It’s believed this is due to the fact girls urethra, which is the outflow pipe from the bladder to the skin is much shorter which makes is easier for bacteria to ascend into the bladder. However, the presence of one urinary tract infection in a child should not be ignored and investigations are useful in order to outrule abnormality of the urinary tract itself.
03. What symptoms will my child get?
In younger children it can be very difficult to determine any symptoms for urinary tract infection. In older children they can present with the more classical symptoms of urinary tract infection just as pain, high fever, fowl smelling urine, pain on voiding, frequency, rushing to the toilet and urinary incontinence.
04. How will I diagnose a urinary tract infection in my child?
If you have any concerns you should bring your child to the GP. A urine specimen should be taken and sent to the lab for microscopy. The best urine to take for urinalysis is a midstream urine, which means your child starts to void and in the middle of the stream, a sample of urine is taken.
05. What are the treatments?
A vast majority of children are suitable to be treated with antibiotics, however further investigations maybe required. Investigations that are useful can be, depending on the child and the symptoms, are at least an ultrasound scan. Occasionally a bladder function assessment which is a noninvasive bladder ‘MOT,’ a DMSA scan which is a nuclear medicine test which will identify kidney scarring and occasionally a micturating cystourethrogram (MCUG) is useful for determining what the internal anatomy is like.
06. Will my child require an operation?
Very rarely is surgery required for children with urinary tract infections and only when there is a distinct problem which is best treated by an operation.
07. Why should urinary tract infections be investigated?
Urinary tract infections can be quite problematic for children. If the infection moves the bladder to kidneys, they can cause significant damage. The child could have prolonged sickness and stay in hospital. The kidney tissue itself can be damaged and the overall function of that kidney can be reduced. The child could also become septic. Some children, when they have complex urinary anatomy, may have urinary tract symptoms or urinary tract infection and have a negative urinary test. In that situation it would be very wise to perform an ultrasound scan.
This information sheet explains how to keep your child’s bladder healthy, reducing the risk of urinary tract infections and other problems with weeing.
How does the urinary system work?
The urinary system consists of the kidneys, the bladder and ureters. The kidneys filter the blood to remove waste products and form urine. The urine flows from the kidneys down through the ureters to the bladder. The ureters tunnel through the wall of the bladder at an angle to form a flap that acts as a valve. There is also a ring of muscle (sphincter) at the junction of the bladder and the urethra that stops urine leaking out in between wees.
When weeing, the muscles of the bladder wall squeeze the urine out of the bladder and at the same time, the muscles in the sphincter relax to let the urine flow down the urethra. The valves between the ureters and bladder prevent urine flowing backwards up to the kidneys.
Keeping your child’s bladder healthy
There are many ways you can encourage your child to have a healthy bladder – here are some suggestions:
Using the toilet
During the school day, your child could make sure they visit the toilet at the start and end of the school day and at every break or playtime. Children may rush going to the toilet if they are worried they will miss exciting playtime so encourage them to spend as long as needed. If your child seems reluctant to use the toilets at school, try to find out why and then talk to their teacher.
The nurses may advise you to encourage your child to go to the toilet at set times – every three to four hours – during the day even if they do not need to pee. Some children find a watch with an alarm a useful reminder to go to the toilet.
Getting in the right position on the toilet is important too – sitting on the toilet seat with legs wide apart resting both feet flat on the floor if they can reach. If your child cannot reach the floor, you can buy a plastic step from most chemists or childcare shops. Boys who stand up to wee should stand with their legs apart in a comfortable natural position.
We may suggest that you encourage your child to use ‘double voiding’. When your child has finished weeing, ask them to stay on the toilet and relax for 20 seconds or so before trying to wee again.
Drinking plenty of fluids
Fluids are vitally important in keeping healthy so encourage your child to drink plenty of liquid throughout the day – more if the weather is hot. It is better to drink small amounts of fluid frequently throughout the day rather than lots in one go when thirsty. Guidance from the National Institute for Health and Care Excellence (NICE) suggest the following amounts for children and young people.
• seven to 12 months – 600ml
• one to three years – 900ml
• four to eight years – 1200ml
• boys aged nine to 13 years – 1800ml
• girls aged nine to 13 years – 1600ml
• boys aged 14 to 18 years – 2600ml
• girls aged 14 to 18 years – 1800ml
Some drinks are better for the bladder than others – drinks containing caffeine or artificial sweeteners or fizzy drinks can irritate the bladder. Fruit squashes are a good alternative to water but only if they are diluted well, but darker coloured squashes such as blackcurrant are best avoided.
If you are not sure which drinks are irritating your child’s bladder, you could try limiting them to milk and water for a couple of weeks before introducing other drinks one at a time.
Avoiding constipation
The same muscles control pooing as well as weeing so constipation can affect how your child wees. Eating a healthy diet with a wide range of fruit and vegetables is usually enough to keep your child’s bowels working properly. Drinking plenty of fluid is important as well. Some families find introducing probiotic yoghurts or drinks, helps avoid constipation. They also change the bacteria in poo reducing the risk of urinary tract infection.
When your child has had a poo, teach them to wipe from front to back as this reduces the risk of germs in poo being transferred to the urethra and then into the urinary system. This is particularly important for girls as there is a shorter distance between the anus and urethra.
Straining to have a poo can weaken the muscles supporting the bladder (pelvic floor muscles). Encourage your child to eat a balanced diet and drink plenty of fluids to prevent constipation. If you are concerned about your child’s constipation, talk to your family doctor (GP) or local community pharmacist (chemist).
Health supplemental
Health supplements such as probiotics e.g. Yakult, Actimel, Cranberry, Blueberry juices, and D-mannose can reduce the risk of developing an infection. Talk to your child’s urology CNS for further details.
Good hygiene
Our skin is our best barrier against infection and the skin around the genitals is no different. Your child should wash every day, paying particular attention to this area. Water and a gentle pH balanced soap is best for keeping clean, but try to avoid using highly perfumed soaps or shower gels as these can be irritating.
Every member of the family should have their own flannel and towel to avoid germs being passed from one person to another. These should be washed frequently on a 60° wash cycle with no biological soap powder or liquid. Towels and flannels do not need fabric softener as this reduces their absorbency.
Top tips:
• Visit the toilet at set times throughout the day – about every two to three hours.
• Get into the right position to wee – stay comfortable and relaxed.
• Try not to rush.
• Rest for 20 seconds and try to wee again.
• Drink plenty of fluids.
• Avoid fizzy drinks, ones containing caffeine or artificial sweeteners or dark coloured squashes.
• Health supplements can help prevent infections.
• Eat a healthy balanced diet to avoid constipation.
• Wipe from front to back.
• Keep the area clean with your own flannel and towel.
For further information, please contact:
We hope that you find this information helpful. If you have any questions or problems either before or after the surgery, please do not hesitate to contact Paediatric Complex Surgical/Urology Nurse, on 020 7580 4400, 10838 (09:00 – 17:00 Monday to Friday) or email at [email protected]
For Out of hours: Contact our Paediatric Site Practitioner via the switchboard on: 02075804400 ex 10843
Disclaimer Whilst this leaflet aims to provide you with useful information, it must be noted that it should only act as a guidance. Should you have any further concerns about UTI, it is advisable that you discuss them with your Consultant.
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If you have any comments or concerns about the services we have provided please let us know by filling out patient’s feedback form, or alternatively you can contact the Patient Experience Team.
Balanitis is an inflammation of the foreskin and occasionally the head of the penis. It is very common in boys and usually resolves in 2-3 days. Most cases settle down without any particular treatment and without any scarring. Occasionally it can recur and be a problem with pain, discharge and scarring.
Here at London Children’s Surgery we try to avoid surgery as much as possible in these patients but if conservative management fails then circumcision is warranted. Balanitis in children isn’t usually serious as the symptoms will usually clear up within a few days. However, it can be very uncomfortable and can keep coming back for some boys so it is important to see a doctor if you suspect that your child is affected.
Symptoms of Balanitis
Balanitis symptoms are usually fairly easy to recognise as they can be very uncomfortable and visible. Most young boys will complain of penile discomfort. It can be itchy with a red and inflamed foreskin and difficulty passing urine. The foreskin can appear tight and a foreskin which was previously retractile is no longer so.
Balanitis symptoms can include:
• Pain when urinating
• Redness
• Whitish spots
• Swelling
• Soreness
• Itchiness
• Build-up of thick fluid
• An unpleasant smell
• Tight foreskin
If you notice any of these symptoms or your child is complaining of soreness or discomfort then you should see a doctor. It is important to determine the cause of these symptoms as they could be signs of an infection that requires treatment. If balanitis symptoms are caused by an infection then there is also a risk that it could spread into the urinary tract and cause further problems. Balanitis that is caused by an infection can also be associated with other symptoms, such as a fever.
The doctor will also be able to advise you on what can be done to prevent the balanitis symptoms from coming back again. In most cases, balanitis in children won’t cause any serious issues and there won’t be any need for surgery. However, surgical balanitis treatments may be recommended if the symptoms keep coming back frequently.
Causes of Balanitis
Balanitis in a small degree nearly affects all men with an intact foreskin. The vast majority of cases are quite mild. Most child get what’s called chemical balanitis which is just a small amount of redness associated with the foreskin releasing. True infected balanitis occurs in approximately 5% of the population of boys of less than 5 years of age.
Balanitis in children can be associated with:
• Poor hygiene leading to the build-up of a material called smegma under the foreskin
• Irritation caused by urine that hasn’t been dried after peeing
• Irritation from soaps, shower gels or other products
• Bacterial or fungal (yeast) infections
• Skin conditions such as psoriasis or eczema
• Irritation due to children pulling or touching the foreskin too much
Balanitis symptoms are more common in boys with an intact foreskin, but the glans can become inflamed even in boys who have been circumcised. If both the foreskin and glans are affected then the condition is sometimes referred to as balanoposthitis.
Boys who have diabetes can be more likely to develop balanitis. Since it can be linked to skin conditions, it can also occur in boys who have conditions such as eczema that may affect the genitals. However, balanitis can affect any boy and it is particularly common in those under the age of 5.
Balanitis in children can also be associated with a condition called phimosis, which happens when the foreskin remain too tight to retract. The foreskin usually separates from the glans and becomes retractable between the ages of 2 and 6. Balanitis symptoms are more likely to occur before the foreskin has retracted or if it remains tight at a later age. Recurring balanitis in children can also increase the chances of phimosis persisting to a later age, if the problem is left untreated.
Treatments of Balanitis
Balanitis in children can usually be diagnosed from the symptoms and an examination of the penis. In some cases, additional tests may be required to rule out other conditions such as infections that can cause similar symptoms. A sample of urine or of any discharge may be taken with a swab so that it can be tested in the lab to check for a bacterial or fungal infection that could be causing the balanitis symptoms.
Most children with balanitis can be managed conservatively and without surgery. Hygiene is very important to ensure the area is kept clean and retracting the foreskin is frequently not advisable. The penis should be kept as clean and as dry as possible. It should be washed with lukewarm water. It isn’t necessary to use soap or other products, which can irritate the delicate skin in this area. The penis should then be dried carefully before getting dressed. The penis should also be dried gently after peeing. If the foreskin has retracted, then the area underneath can be cleaned and dried carefully too, but you shouldn’t pull back a foreskin that has not retracted yet as this could be painful and might damage it.
Parents will be responsible for ensuring the penis is cared for properly during the early years, but it is important to ensure that boys learn how to take care of their bodies as they grow older so that they can continue to practice good hygiene for themselves. Cleaning the penis properly can relieve balanitis symptoms and reduce the chances of the condition coming back again in the future.
There is an occasional role for antibiotics or for topical creams. Different balanitis treatments can be recommended to tackle different causes of irritation. For example, antibiotics may be prescribed to clear up a bacterial infection while antifungal creams can be used to treat yeast infections. In many cases, balanitis in children is simply due to irritation rather than an infection. A steroid cream may then be recommended for balanitis treatment to soothe the symptoms.
Balanitis symptoms should begin to improve within a few days, but it is important to complete the full course of balanitis treatment if the doctor has prescribed any medication. Balanitis treatment is usually very effective and with good personal hygiene the chances of the symptoms coming back can be minimised.
Balanitis Surgery
Most children who get balanitis will get a second episode. However, ensuring that the penis is kept clean and dry can reduce the chances that the condition will come back.
It is usually not severe and rarely is circumcision warranted. If it is very problematic a circumcision is warranted. See circumcision information.
Circumcision surgery can reduce the chances of balanitis coming back again, but it cannot eliminate the risk of inflammation and infection entirely. The glans can still become irritated or infected if it is not cared for properly, so practicing good hygiene and teaching boys how to take care of their bodies will still be essential.
Balanitis FAQs
01. What is Balanitis?
Balanitis is an inflammation of the foreskin, which is called the prepuce. In many situations the inflammation is relatively mild. Balanitis in children can be the result of an infection but it can also be caused by simple irritation.
02. Who gets this and how often?
Balanitis in a small degree nearly affects all men with an intact foreskin. The vast majority of cases are quite mild. Most child get what’s called chemical balanitis which is just a small amount of redness associated with the foreskin releasing. True infected balanitis occurs in approximately 5% of the population of boys of less than 5 years of age.
03. What are the symptoms?
Most young boys will complain of penile discomfort. It can be itchy with a red and inflamed foreskin and difficulty passing urine. The foreskin can appear tight and a foreskin which was previously retractile is no longer so.
04. How is Balanitis diagnosed?
Balanitis in children can usually be diagnosed based on the symptoms and an examination of the penis. Further tests may be needed to identify the cause of the condition if it is due to a bacterial or fungal infection as this can help to guide the treatment. Infections can be identified by a urine test or by taking a sample of any pus or discharge using a cotton swab.
05. How is Balanitis managed?
Most children with balanitis can be managed conservatively and without surgery. Hygiene is very important to ensure the area is kept clean and retracting the foreskin is frequently not advisable. The penis should be kept as clean and as dry as possible. It should be washed with lukewarm water. There is an occasional role for antibiotics or for topical creams.
06. What medications are used for Balanitis treatment?
Medication is sometimes recommended to relieve balanitis symptoms or to tackle the infections that can sometimes cause balanitis in children. Steroid creams can be used to relieve inflammation. Antibiotics or antifungal medications can be prescribed to clear up different kinds of infection. However, medication isn’t always required for balanitis treatment as the symptoms will often go away when the area is cleaned and cared for correctly.
07. Is there a role for circumcision?
Most children who get balanitis will get a second episode. It is usually not severe and rarely is circumcision warranted. Surgical balanitis treatment will only be recommended when the symptoms keep coming back or don’t respond to other types of balanitis treatment.
08. How can Balanitis be prevented?
Good personal hygiene is the best way to prevent balanitis symptoms from occurring. The glans and foreskin need to be kept clean and dry to reduce the risk of infections or irritation. The foreskin should be treated gently and never pulled back before it has retracted naturally. Soap and other products that could irritate the skin should not be used in this area.
09. Can a baby get Balanitis?
Balanitis can happen at any age, including in babies or toddlers who are still wearing nappies. If your child is in nappies then it is essential to ensure you’re changing them often in order to reduce the risk of balanitis. You should clean and dry the penis and foreskin during every change but avoid using baby wipes to do this as they can irritate the foreskin.
10.How common is Balanitis in children?
Balanitis is fairly common, especially in uncircumcised boys under the age of 5. Approximately 5% of boys will develop balanitis before this age. Many of these boys will have the condition more than once. Balanitis can affect older children and adults too, but it becomes less common once the foreskin has retracted and as boys learn how to practice better personal hygiene. However, most men will experience some balanitis symptoms at some point in their lives.
11.What are the possible complications of Balanitis?
Balanitis in children doesn’t usually cause any serious problems but there can be complications in severe or persistent cases that don’t get the right balanitis treatments. One potential complication of balanitis is that an infection could spread into the urinary tract. Another possible complication is that if the balanitis symptoms are severe they can damage the foreskin, causing scarring that could result in permanent urinary problems or discomfort. Persistent balanitis can also lead to phimosis in some cases, which could prevent the foreskin from retracting normally. If there is any permanent damage to the foreskin after balanitis treatment then surgery may be needed to correct the problem.
12.When should my son see a doctor about Balanitis?
You should always consult a doctor if you notice any symptoms of balanitis. It is important to find out what is causing these symptoms and to get advice on how to manage them. Although balanitis isn’t usually serious, it can be very uncomfortable for your son and in rare cases it can lead to complications such as scarring if it is left untreated. It is particularly important to see a doctor if the symptoms last longer than a few days or if they keep coming back as your son may need additional treatment to prevent balanitis.
Balanitis xerotica obliterans (BXO) is also known as lichen sclerosis atrophicus of the male genitalia is a chronic inflammatory process which affects the foreskin but can also extend onto the glans and external urethral meatus. The top of the foreskin will not retract and there can be pale scarred areas around the tip of the foreskin. It can be extremely painful but present in boys with difficult in voiding. Management is a formal circumcision. Post operatively topical steroids will be applied to decrease the need for further surgery. Additional procedures are sometimes required to ensure that the urethral opening is clear if it has been blocked by scarring or thickened tissue.
Symptoms of BXO
Generally young men complain of discomfort. Sometimes the penis is sore and burning. The foreskin becomes tighter and tighter and is unretractable. It can consist of bleeding and occasionally there can be small tears visible at the top of the foreskin. Young men can find that their ability to void slows gradually over time.
BXO on examination, the top of the foreskin is quite tight and cannot be retracted. Generally, the issues can look quite variable. Occasionally the skin over the top of the penis will be very white and shiny. Sometimes the skin can become quite inflamed or on some occasions it can be quite thin and very pale or alternatively quite thick. It is important to seek medical advice if there are any concerns as it will need to be treated.
The symptoms of BXO can appear as:
• A hard, scaly or whitish lump that forms around the urethral opening (also known as the meatus)
• Inflammation of the glans or foreskin
• Tightening of the foreskin that may prevent it from retracting or from returning back over the glans
• Bleeding or tears on the foreskin
• Pain or difficulty passing urine
• Weak flow of urine
• Urine spraying rather than flowing out steadily
• Itchiness, burning or soreness around the glans and foreskin
• Discharge from the penis
Since the symptoms of BXO can be so variable, it is important to see a doctor if you notice anything unusual about the penis or your son complains of pain or problems when urinating. BXO is generally diagnosed on clinical examination and the tissue is normally sent for histology if the child is circumcised to confirm this.
Causes of BXO
In reality, the cause for this condition is unclear. It generally affects men who are uncircumcised. It is extremely rare in those young boys who have been circumcised in the neonatal period. There is no evidence of any infection and no particular cause has ever been detected.
Although we don’t fully understand the causes of BXO, some scientists believe that it could be associated with other types of autoimmune conditions such as vitiligo. Autoimmune disorders cause inflammation because the immune system mistakenly starts to attack the body’s own tissues. We don’t know why this happens and it isn’t yet possible to predict who will be affected. However, we do know that boys who have autoimmune disorders or atopic conditions such as eczema, hay fever or asthma are more likely to develop balanitis xerotica obliterans.
You may hear the term lichen sclerosis used to refer to your son’s condition. Lichen sclerosis is a chronic inflammatory condition that can affect the skin in different parts of the body. When it affects the male genitalia, it is known as balanitis xerotica obliterans or BXO.
Lichen sclerosis is not an infection so there is no risk that it will spread to other people. The condition is chronic and progressive, which means that it is a long term condition that will gradually get worse if it is left untreated. Lichen sclerosis causes inflammation that can make the penis sore and red. The opening of the urethra may become narrowed or blocked and an ulcer can eventually form. The skin of the glans and foreskin can be permanently changed or scarred.
Treatments of BXO
At this moment in time we recommend circumcision to be performed. There is some debate that foreskins can be left intact with injection of steroids or the use of topical steroids. This has currently not been proven and due to the ongoing risks associated with this condition, we would recommend a formal circumcision to ensure this is BXO through histology and guarantee the situation has treated properly. Since BXO is a progressive and painful condition, it is usually best to tackle it swiftly with surgery rather than to wait to see if other, less reliable treatments might help.
Circumcision is the main component of balanitis xerotica obliterans treatment, but it is also vital to follow the post-surgical treatment plan to reduce the risk of further problems. Medication can prevent the urethra from becoming narrower after the operation. In some cases, further surgery may be required to ensure that the urethra is able to function properly.
BXO Post-Surgery
We prescribe a small amount chloramphenicol cream to be used for a number of days to allow the tissues to settle down. At around 5 days after surgery, a course of hydrocortisone cream is used twice a day for 6 weeks to stop the meatus from narrowing. It is our experience that this may help make a significant difference to the insistence of meatal stenosis in this population. Your child will then attend a follow-up review to ensure that their opening is nice and wide and they are voiding without any difficulties.
BXO if left for the long term can be extremely severe and cause a huge amount of pain. Prolonged BXO can also allow the opening of the penis to narrow and this can require the need for further surgery and dilatation. There is also an association with penile cancer in later life if undiagnosed.
Balanitis xerotica obliterans surgery is usually very effective, especially when circumcision is combined with post-operative medication. However, there is a small chance that the remaining skin will still be affected by lichen sclerosis.
Balanitis Xerotica Obliterans FAQs
01. 01. What is balanitis xerotica obliterans (BXO)?
Balanitis xerotica obliterans is a chronic inflammatory process of the foreskin and is also known as lichen sclerosis. Inflammation occurs when the immune system is active. It can result in redness, swelling, pain and other symptoms.
02. What causes BXO?
In reality, the cause for this condition is unclear. It generally affects men who are uncircumcised. It is extremely rare in those young boys who have been circumcised in the neonatal period. There is no evidence of any infection and no particular cause has ever been detected
03.What is lichen sclerosis?
Lichen sclerosis is a chronic inflammatory condition. When it affects the skin on the penis, it is known as balanitis xerotica obliterans. Lichen sclerosis can affect other parts of the skin too. It can appear as whitish patches but it doesn’t usually cause much discomfort unless it is affecting the penis.
04. What are the symptoms of BXO?
Generally young men complain of discomfort. Sometimes the penis is sore and burning. The foreskin becomes tighter and tighter and is unretractable. It can consist of bleeding and occasionally there can be small tears visible at the top of the foreskin. Young men can find that their ability to void slows gradually over time.
05. What is the appearance of BXO?
BXO on examination, the top of the foreskin is quite tight and cannot be retracted. Generally, the issues can look quite variable. Occasionally the skin over the top of the penis will be very white and shiny. Sometimes the skin can become quite inflamed or on some occasions it can be quite thin and very pale or even quite thick. It is important to seek medical advice if there are any concerns as it will need to be treated.
06. How common is BXO?
Balanitis xerotica obliterans isn’t a very common condition. It affects less than 5% of men and boys. The condition is slightly more common in boys who have autoimmune disorders or atopic conditions such as asthma and eczema, but it still only affects a small proportion of these boys.
07. When should my son see a doctor about BXO?
If your son has symptoms of BXO then it is important to see a doctor as the condition can get worse if it is left untreated. Surgery can relieve the discomfort and prevent the urethra from becoming any narrower so it is usually the best option for treatment
08. How is it diagnosed?
BXO is generally diagnosed on clinical examination and the tissue is normally sent for histology if the child is circumcised to confirm this. It is important to be sure that the symptoms were caused by BXO as the problem could come back if there is another issue that needs to be addressed.
09. How is it treated?
At this moment in time we recommend circumcision to be performed. There is some debate that foreskins can be left intact with injection of steroids or the use of topical steroids. This has currently not been proven and due to the ongoing risks associated with this condition, we would recommend a formal circumcision to ensure this is BXO through histology and guarantee the situation has treated properly.
10. What happens after the circumcision?
We prescribe a small amount chloramphenicol cream to be used for a number of days to allow the tissues to settle down. At around 5 days after surgery, a course of hydrocortisone cream is used twice a day for 6 weeks to stop the meatus from narrowing. It is our experience that this may help make a significant difference to the insistence of meatal stenosis in this population. Your child will then attend a follow-up review to ensure that their opening is nice and wide and they are voiding without any difficulties.
11. Will my son need further surgery?
Circumcision is usually enough to relieve the symptoms of balanitis xerotica obliterans when it is performed together with post-operative hydrocortisone treatment. However, if the condition has progressed too far before the circumcision, further procedures may be required to open up the urethra so that urine can flow out freely.
12. What can I do to help manage BXO?
Surgery is an essential part of balanitis xerotica obliterans treatment, but there are also some things you can do to relieve the symptoms. The most important thing your can do is to ensure that the glans and foreskin are kept as clean and dry as possible. The penis should be washed with lukewarm water and then dried carefully. Avoid using soap or other products that could cause more irritation. It is also important to ensure the penis is dried properly after urination. In addition to ensuring good personal hygiene, you can also help by following the doctor’s instructions after the operation and attending the follow up appointments.
13.What are the complications?
BXO if left for the long term can be extremely severe and cause a huge amount of pain. Prolonged BXO can also allow the opening of the penis to narrow and this can require the need for further surgery and dilatation. There is also an association with penile cancer in later life if undiagnosed. Untreated BXO could also cause sexual problems once boys have grown up, especially if the opening of the penis has been narrowed.
14.How does BXO affect the risk of penile cancer?
Balanitis xerotica obliterans is not a form of cancer and it does not mean that your son will definitely go on to develop penile cancer. However, balanitis xerotica obliterans is considered a precancerous condition. If balanitis xerotica obliterans is not treated promptly then it can eventually lead to changes in the cells that could develop into cancer. This is why it is so important to see a doctor if you think that your son might be affected. Circumcision can reduce the risk of penile cancer in men or boys who have BXO. However, it is important to know that the risk of penile cancer is still very low, even in boys who have been affected by BXO.
Phimosis is a condition that prevents the foreskin from retracting properly from the head of the penis. The foreskin is usually fixed in place in young children, but it should begin to loosen during early childhood. The foreskin will normally be able to retract and then move back into place over the head or glans of the penis. However, sometimes this doesn’t happen and the foreskin remains unable to retract. In other cases, the problem develops later and the foreskin is no longer able to retract as it used to do.
True phimosis occurs when a scar occurs on the foreskin and prevents the foreskin from retracting. It is important to differentiate this from BXO. Normally phimosis can be treated with topical steroids for 4 to 6 weeks. Occasionally if the steroids do not work or the scarring is too excessive circumcision is required. Phimosis surgery is a fairly straightforward procedure that can relieve the discomfort of this condition.
Symptoms of Phimosis
The vast majority of children with phimosis have evidence of ballooning of the foreskin or are unable to retract the foreskin and some swelling at the tip of the foreskin when it’s been retracted. Discomfort and pain can present. They would be able to partially retract some but not the entire foreskin. They can have discolouration of the glans and penis when it’s partially retracted.
One of the most common phimosis symptoms is the bulging or ballooning of the foreskin during urination. This happens because urine builds up inside the foreskin as it makes its way out. It can sometimes happen even if the foreskin is normal, especially in younger boys whose foreskin has not fully retracted yet. In some cases, phimosis can cause other kinds of urinary problems too. Severe phimosis may make it harder to pass urine. It can also increase the risk of issues such as balanitis, which happens when the foreskin gets inflamed due to irritation or an infection.
It is important to be aware that the foreskin cannot usually be retracted at a young age. The foreskin usually becomes looser during early childhood. The process usually begins by age two to three, but it can take longer for the foreskin to be able to retract completely. You should never try to force the foreskin to retract as this could damage it. If the foreskin becomes scarred then it might not be able to retract properly in the future and phimosis surgery may then be required to correct it.
Phimosis isn’t usually anything to worry about unless it is causing pain or other phimosis symptoms. When it occurs at a young age, the problem will often correct itself in time without the need for phimosis surgery. However, if you are concerned that the foreskin is taking longer than expected to retract, it can be reassuring to see a doctor. You should also seek medical advice if your son is experiencing any phimosis symptoms or if the foreskin stops being able to retract later on. Older boys may also feel self-conscious or anxious about phimosis, so it can be important to talk to them about the condition and enable them to speak to a doctor if they wish.
Causes of Phimosis
Phimosis is when the foreskin cannot be retracted from the tip of the penis. By late adolescence, the foreskin can usually be fully pulled back from the glans and is then able to return into place.
A vast majority of young boys have what’s called physiological phimosis. This means it’s a normal variation. When the boy is born the foreskin is partially attached to the top of the penis. It can take time for this to release and for the glans of the penis to become visible. In most cases, the foreskin will start to retract between the ages of about 2 and 6.
Most young boys will start to find that their foreskin starts to retract and by adolescence the vast majority of boys have a fully retractile foreskin. Medication or phimosis surgery is only required if this doesn’t happen naturally. It is important not to rush the process by trying to move the foreskin back as this could damage it.
Phimosis can occur however when the foreskin has already been pulled back. This is when the tissue becomes scarred and fibrous and stops the foreskin from retracting properly. When the condition occurs due to scarring it is sometimes known as true phimosis. The foreskin can be damaged in different ways, including by attempts to force it to retract when it is still too tight. Phimosis surgery may then be needed.
Treatments of Phimosis
Phimosis can usually be diagnosed through a physical examination of the penis and foreskin. The doctor will also ask about any phimosis symptoms that you or your child have noticed. The examination will help to rule out balanitis xerotica obliterans, a skin condition that can prevent the foreskin from retracting. The doctor will also check for scarring or damage to the foreskin that could be responsible for phimosis symptoms.
Most children do not require any treatment for phimosis. If there are no signs of damage and the foreskin has never been able to retract then it can be best to wait and see if it happens naturally as long as your child is still young enough and isn’t experiencing any phimosis symptoms.
However, phimosis surgery or other treatments may be recommended for older children if it is unlikely that the foreskin will begin to retract by itself. Phimosis surgery may also be needed if your child is in pain or having issues such as urinary problems.
Some children will be successfully treated with a treatment of hydrocortisone if there is no significant scarring or any evidence of BXO. Medical phimosis treatment usually involves applying a steroid cream to the foreskin in order to encourage it to become looser.
A small number of children will require surgical intervention. Surgery is only recommended for phimosis treatment when the condition is unlikely to correct itself, the symptoms are severe or it is associated with scarring or damage.
Phimosis Surgery
In reality there are two options, one of which is a small releasing incision to release the fibrotic scar and another is a Circumcision. Overall we recommend a formal circumcision as the dorsal releasing incision can have quite an unsatisfactory cosmetic result and may require a formal circumcision in later life in order to resolve the appearance.
Circumcision is a relatively straightforward procedure. When it is performed for phimosis treatment it typically requires a general anaesthetic. The foreskin can then be removed surgically while your child is asleep and unaware of what is going on. The surgical incision will be stitched up and it should heal completely over the next week or two. It is vital to keep the surgical wound clean and dry while it heals to reduce the risk of infection. Your son may also need painkillers to relieve any discomfort.
Once the foreskin has been removed, the glans of the penis will be exposed. Circumcision should solve any issues linked to phimosis, such as urinary problems. However, it is important to be aware that it will change the appearance of the penis and can affect its sensitivity too. You will need to discuss the risks and benefits of circumcision for phimosis treatment with the doctor. It is also important to talk to your son about the procedure in an age-appropriate way so that he understands what is happening.
Phimosis FAQs
01. What is phimosis?
Phimosis is when the foreskin cannot be retracted from the tip of the penis. Although this is normal in babies and toddlers, the foreskin should naturally begin to loosen between the ages of about two and six. If this doesn’t happen or if the foreskin stops being able to retract, then phimosis treatment may be required.
02. What causes phimosis?
A vast majority of young boys have what’s called physiological phimosis. This means it’s a normal variation. When the boy is born the foreskin is partially attached to the top of the penis. The tip of the foreskin is also usually too narrow to allow it to pass over the glans. It can take time for this to release and for the glans of the penis to become visible.
Most young boys will start to find that their foreskin starts to retract and by adolescence the vast majority of boys have a fully retractile foreskin. It is important to be patient and to allow the foreskin to retract by itself as forcing it back could damage it.
Phimosis can occur however when the foreskin has already been pulled back. This is when the tissue becomes scarred and fibrous and stops the foreskin from retracting properly.
03.How common is phimosis?
Phimosis is normal at a young age, but the foreskin should start to become looser in early childhood. Only 10% of boys will still have a tight foreskin at the age of 7 and only 1% will still be affected by phimosis at the age of 17. If there are no signs of the foreskin becoming looser by the age of five or six it can be a good idea to consult a doctor. Treatment might not be required right away, but it can be helpful for phimosis patient UK to talk to an expert about the condition.
04. What are the symptoms of phimosis?
The vast majority of children with phimosis have evidence of ballooning of the foreskin or are unable to retract the foreskin and some swelling at the tip of the foreskin when it’s been retracted. Discomfort and pain can present. They would be able to partially retract some but not the entire foreskin. They can have discolouration of the glans and penis when it’s partially retracted.
05. How is it treated?
Most children do not require any treatment for phimosis. The condition often corrects itself as children grow up. Some children will be successfully treated with a treatment of hydrocortisone if there is no significant scarring or any evidence of BXO. A small number of children will require surgical intervention. The main surgical option for phimosis patient UK is circumcision. However, sometimes it is possible to remove a smaller section of the foreskin if the problem is caused by scarring.
06. What surgery is recommended for childhood phimosis?
In reality there are two options for phimosis patient UK, one of which is a small releasing incision to release the fibrotic scar and another is a Circumcision. Overall we recommend a formal circumcision as the dorsal releasing incision can have quite an unsatisfactory cosmetic result and may require a formal circumcision in later life in order to resolve the appearance.
07. What are the risks of circumcision for phimosis treatment?
Some pain and swelling is normal after circumcision, but the side effects are usually manageable. The risk of serious complications is low for phimosis patient UK, but there is still a chance of issues such as an infection, bleeding or allergic reactions to the anaesthetic used during the procedure. You will need to discuss these risks in detail with the doctor before your son has the operation.
08. What are the complications?
There can be significant pain. It can also impact on the child’s voiding. Phimosis can increase the chances of developing infections or balanitis. Boys can also become self-conscious about the condition as they grow older, which could affect their confidence or cause issues such as anxiety. Even if there are no physical phimosis symptoms it can still be important to consider the mental impact of this condition.
09. When should my son see a doctor about phimosis?
If your son is experiencing any discomfort, urinary problems or other phimosis symptoms then you should consult a doctor. It is also a good idea to talk to a doctor if the foreskin isn’t getting any looser by the age of about five or six. Phimosis treatment might not be needed immediately as the foreskin may still retract by itself over time. Treatment may also be required if the foreskin stops being able to retract later on.
When the baby is being formed, the testes are initially made up in the abdomen, near the kidneys. They then go through a process called testicular descent whereby the testes descend down through the abdomen and into the scrotum. Isn’t nature amazing?. However, sometimes the testes fail to descend normally and can be halted at any point along the way, hence the term undescended testes. Most of the time they are halted outside the abdominal cavity and are “stuck” in the groin. Sometimes though they can be halted inside the abdominal cavity.
Symptoms
Most children do not complain about having undescended testes. It is normally diagnosed at the time of birth or at the 6-week check. Some parents will also notice that the testicle would appear missing when changing the child’s nappy or bath time. Both testes should be present at the base of the scrotum by 3 months of age and if they are not, they will require surgery. Occasionally children will develop an ascending testes, this occurs in older children between the ages of 7 – 11 years old of which the testicle was in a normal position then moves out of the scrotum. Once again, these young boys do not generally notice this change but are spotted by their parents when they are being showered or bathed.
Causes
In reality, we do not really understand as to why children develop undescended testes. It is a very common condition affecting 1 in 100 boys. If a boy has undescended testes, he increases the risk for his relatives having undescended testes, both the siblings and his own children. However, the vast majority cases are spontaneous and there is no distinct cause or risk factor.
Treatments
Without a doubt, the most useful and successful treatment for undescended testes is an Orchidopexy. This consists of an operation which brings the testicle down into the base of the scrotum and fixes it into that position.
Surgery
If the testes are palpable and it can be felt during clinical examination, the operation will consist of an incision in the groin and the testis is freed up. Frequently there is a small hernia present which is repaired at the same time. The testes are brought down into the scrotum, a small incision is made and is placed into a small pouch.
If the testicle is not palpable, a keyhole procedure will occur in which a camera is placed into the abdomen. If the testis is present in a reasonable shape, a two-stage procedure will be required in order to bring it down into the scrotum.
Post-Surgery
A vast majority will be able to go home the same day and do extremely well.
Undescended Testes FAQ’s
01. What is Orchidopexy?
Orchidopexy is the name of the operation for bringing undescended testes down into the scrotum. A small cut is made in the groin. The testes are released and a hernia which is present is repaired. Another incision is made in the scrotum and the testes is placed in the correct position.
02. Why do patients need this procedure?
Testes should be in the scrotum by 3 months of age. If they are not in the correct position then they need an operation to bring them down. Bringing the testes down to the correct position maximises the potential fertility for the child and can decrease their cancer risk.
03. Will my child need a general anaesthetic if surgery is needed?
A general anaesthetic is necessary for orchidopexy. It is very safe and well tolerated by children.
04. Will my child be able to go home the same day?
The vast amount of boys will be able to go home on the same day after the operation. Occasionally if both testis are brought down then the child may need to stay one night.
05. What happens during procedure?
Your son will be brought to the theatre. He will receive general anaesthetic and be given local anaesthetic as well. Two incisions are made, one in the groin to free up the testes and another in the scrotum where the testes are placed.
06. Are there any risks?
The risks of orchidopexy are low. The risk from the general anaesthetic is extremely low. Infection, bleeding and swelling can occur in less than 3% of patients. Occasionally the testes is too small and has to be removed. Rarely the testes do not grow or shrinks after the operation and sometimes has to be removed.
07. How long will it take to recover?
Normally boys recover fully within 3 days.
08. How do I care for my son when he gets home?
Occasionally there can be some nausea within the first feed hours of the surgery. Baths should be avoided for 5 days. Otherwise regular pain is necessary for the first few days. Other than that the child should be treated normally.
09. When will they be able to go back to school?
Most boys are able to return to school after 5 days. A few boys go back sooner. Parents are the best judge of their own sons.
10. Will my child need any medication?
After going home from the hospital, the only medication, you will need is the routine pain analgesics which you will give regularly for the first few days.
11. Are hormones used in treating undescended testes?
There is some evidence relating to hormone usage. However national guidance advises strongly against hormone usage and suggests surgery is the correct option.
Hypospadias is a condition affecting the penis which occurs in 1 in 200 new born males. The meatus/ opening is lower than the traditional position, the foreskin can be partially missing, the penis can appear bent and rotated. Frequently this is diagnosed at birth which can be very stressful and worrisome for the parents and family.
Parents are worried about what will happen in school, will the child ‘wee’ straight, will he be teased and what will happen when is an adult.
Here at London Children’s Surgery we are experts in the management of hypospadias. We recognise that there is a huge amount of anxiety and stress about the condition and our aim at the initial consultation is to explain the problem and reassure the parents and the older child. We will explain all the surgical options and their outcomes and help you make the best choice for your child. If you choose an operation with us we will walk with you every step of our journey.
Diagnosis:
Hypospadias is usually diagnosed at birth by clinical evaluation of the appearance of the penis. Most boys are then assessed when a few months’ old, so that surgical repair can be planned. The timing of surgery is variable and non – urgent, however initial surgery usually occurs between the age of 6
Symptoms
Hypospadias consist of the opening (meatus) being in a misplaced position. It can be lower on the head of the penis, it can be down on the shaft of the penis or it can occasionally be found at the base of the penis in the scrotum. It can be associated with a hooded foreskin, some rotation of the skin of the penis or some curvature of the penis (chordee).
Normally this condition is diagnosed around the time of birth or in the medical check-ups after that. Occasionally mild forms are identified later on in life or at the time of circumcision. Hypospadias rarely causes symptoms in children.
Causes
Hypospadias is a condition where the opening for the ureter is lower down on the penis than in the classical position at the end.
There are no particular known causes for Hypospadias. It can occur in 1 in 300 births. Some children with complex medical conditions have a slightly higher risk of having Hypospadias but the vast majority of young boys spontaneously present with this condition and is not related to anything else.
Treatment
Many children can have a mild form of hypospadias and conservative management is entirely appropriate. There are a huge number of options and surgery available for hypospadias. The philosophy of our group is to do minimalistic surgery.
One option is to leave the child alone as there is no significant cosmetic or functional impact. Another option is to perform a foreskin reconstruction and a minor hypospadias repair. The third option is a more formal Hypospadias repair. There are of course, other options available for children with a more severe form of Hypospadias where the opening is much closer towards the base of the penis and usually requires reconstructive surgery which is performed in a staged fashion.
Pre-Surgery
Your child will attend the hospital and will need to be appropriately fasted. The procedure will be explained in detail prior. Operation will be performed under general anaesthetic and in a vast majority of cases; child will be able to go home the same day. Most children do require a catheter to be inserted and have a dressing on, but this will all be explained before and after the operation.
Post Op
If your child has a catheter and a dressing in place, your child will be able to go home with these on. Normally the dressing is left on for 5 – 7 days and you child will return to the hospital at this time to have their dressing removed. During this time, most children will have a regular course of pain relief such as Nurofen and Paracetamol. They will also be prescribed a preventative antibiotic, such as Trimethoprim and an anticholinergic in order to relax their bladder. Some children do suffer from bladder spasms with the catheter in place and hence the reason for the bladder relaxant. It is important that the bladder relaxant medication is stopped the night before the dressing is removed in order to ensure the child is able to void the following day when the catheter is removed.
During the time the dressing is in place, we recommend to keep the area dry and clean. No baths are allowed as this would disrupt the dressing and be very uncomfortable for the child. The easiest way forward is once the dressing and catheter are removed, the child can have regular baths and return to normal activity.
FAQ’s
01. What is Hypospadias?
Hypospadias is a condition where the opening for the ureter is lower down on the penis than in the classical position at the end.
02.What are the causes?
There are no particular known causes for Hypospadias. It can occur in 1 in 300 births. Some children with complex medical conditions have a slightly higher risk of having Hypospadias but the vast majority of young boys spontaneously present with this condition and is not related to anything else.
03.What is the appearance of a Hypospadias?
Hypospadias consist of the opening (meatus) being in a misplaced position. It can be lower on the head of the penis, it can be down on the shaft of the penis or it can occasionally be found at the base of the penis in the scrotum. It can be associated with a hooded foreskin, some rotation of the skin of the penis or some curvature of the penis (chordee).
04. When is this diagnosed?
Normally this condition is diagnosed around the time of birth or in the medical check-ups after that. Occasionally mild forms are identified later on in life or at the time of circumcision.
05. What are the options of treatment?
Many children can have a mild form of hypospadias and conservative management is entirely appropriate. There are a huge number of options and surgery available for hypospadias. The philosophy of our group is to do minimalistic surgery.
One option is to leave the child alone as there is no significant cosmetic or functional impact. Another option is to perform a foreskin reconstruction and a minor hypospadias repair. The third option is a more formal Hypospadias repair. There are of course, other options available for children with a more severe form of Hypospadias where the opening is much closer towards the base of the penis and usually requires reconstructive surgery which is performed in a staged fashion.
06. What will happen on the day of surgery?
Your child will attend the hospital and will need to be appropriately fasted. The procedure will be explained in detail prior. Operation will be performed under general anaesthetic and in a vast majority of cases; child will be able to go home the same day. Most children do require a catheter to be inserted and have a dressing on, but this will all be explained before and after the operation.
07. What happens after the operation?
If your child has a catheter and a dressing in place, your child will be able to go home with these on. Normally the dressing is left on for 5 – 7 days and you child will return to the hospital at this time to have their dressing removed. During this time, most children will have a regular course of pain relief such as Nurofen and Paracetamol. They will also be prescribed a preventative antibiotic, such as Trimethoprim and an anticholinergic in order to relax their bladder. Some children do suffer from bladder spasms with the catheter in place and hence the reason for the bladder relaxant. It is important that the bladder relaxant medication is stopped the night before the dressing is removed in order to ensure the child is able to void the following day when the catheter is removed.
08.What happens with the dressing?
During the time the dressing is in place, we recommend to keep the area dry and clean. No baths are allowed as this would disrupt the dressing and be very uncomfortable for the child. The easiest way forward is once the dressing and catheter are removed, the child can have regular baths and return to normal activity.
09.Is follow-up required?
Generally, the child is seen 6 – 8 weeks after surgery when most of the healing has occurred.
10. What are the complications of the operation if you choose to opt for surgery?
The complications do vary depending on the type and extent of the procedure you choose for your child. Operations which are more complicated have a slightly higher complicated rate and overall the risk of complications nationally is around 10 – 15%. Common complications consist of wound infections, the appearance of a fistula (which is a small leak) swelling or bruising.
Vesicoureteric reflux (VUR) is the result of an abnormality in the valve between the tube from the kidney (ureter) and bladder (vesico). A normal vesico-ureteric valve allows urine to travel only in one way from the kidney to the bladder. The valve does not work then reflux occurs, allowing urine to go back out of the bladder and up the ureter and up to the kidney.
VUR can be present from birth or can occur later in childhood. Although it is very common to have VUR it is usually only problematic when the child has had a urine tract infection as there is a risk of renal damage. Occasionally dilated ureters are seen on antenatal scans and further tests are needed after the baby’s birth. At London Children’s Surgery we recognise that most children with VUR do not require surgery and with careful monitoring children can be kept infection free. We provide a comprehensive management plan for vesicoureteric reflux from initial diagnosis, treatment and follow up.
Symptoms
Vesicoureteric reflux is at times diagnosed on antennal scan. If on this scan there is evidence of the ureter being dilated or the ureter changing size and shape this can lead to a diagnosis of VUR. In the postnatal period, it’s important for the child to have further investigations to prove this diagnosis.
Most children are diagnosed after a urinary tract infection. UTI in children can be quite variable. Some children present a high temperature and vomiting with a reduced appetite and foul smelling urine. In an older child it can be associated with abdominal pain when voiding, frequent visits to the toilet and rushing to the toilet.
Causes
VUR occurs in 1 in 100 to 1 in 150 boys. It is much more common in girls than in boys and can run in the family. If an older sibling has VUR, it’s important that their siblings are screened.
The exact cause of VUR is still debated. Simplistically the ureter is the tube which drains the urine from the kidney and empties into the bladder. As the ureter enters the muscle of the bladder there is a small valve like structure. If the tunnel to the bladder wall is not long enough, the valve which stops urine going from the bladder back up into the ureter does not work properly. If this valve is incompetent or fails to work, the urine will easily reflux from the bladder back up into the ureter. Reflux of urine can occur when the child is voiding or when the bladder is filling.
Treatment
In the vast majority of children, the management is really focused on improving bladder function, emptying their bladder well and stop the infections. Therefore the use of antibiotics is used in first line treatment in order to prevent urinary tract infections and maintain kidney function. If the child continues to get ongoing urinary tract infections despite being treated unsuccessfully, there can be then need for surgery. However, most children do not require surgical intervention.
Surgery
The vast majority of children can be treated with a keyhole operation. This consists of a procedure where a small camera is inserted into the bladder through the urethra. This enables us to see where the urethral opening is. A small amount of material is injected into the valve to improve the valve mechanism. This is a very successful day case procedure and has very low complications.
In the past, a very common operation called ureteric re-implantation was performed. This is a basic procedure where the bladder is opened, the ureters are disconnected from the bladder and then re-implanted and reattached in a new fashion to make a longer tunnel which recreates a newly functioning valve. The child will require staying in hospital for a few days following the surgery. In general, this operation is required less frequently and the vast majority can be treated with endoscopic method.
FAQ’s:
01. How common is VUR?
VUR occurs in 1 in 100 to 1 in 150 boys. It is much more common in girls than in boys and can run in the family. If an older sibling has VUR, it’s important that their siblings are screened.
02.What causes VUR?
The exact cause of VUR is still debated. Simplistically the ureter is the tube which drains the urine from the kidney and empties into the bladder. As the ureter enters the muscle of the bladder there is a small valve like structure. If the tunnel to the bladder wall is not long enough, the valve which stops urine going from the bladder back up into the ureter does not work properly. If this valve is incompetent or fails to work, the urine will easily reflux from the bladder back up into the ureter. Reflux of urine can occur when the child is voiding or when the bladder is filling.
03. Can this be diagnosis antenatally?
Vesicoureteric reflux is at times diagnosed on antennal scan. If on this scan there is evidence of the ureter being dilated or the ureter changing size and shape this can lead to a diagnosis of VUR. In the postnatal period, it’s important for the child to have further investigations to prove this diagnosis.
04.What are the signs/ symptoms in an older child?
Most children are diagnosed after a urinary tract infection. UTI in children can be quite variable. Some children present a high temperature and vomiting with a reduced appetite and fowl smelling urine. In an older child it can be associated with abdominal pain when voiding, frequent visits to the toilet and rushing to the toilet.
05. How is VUR diagnosed?
Ultrasound scan is useful for detecting any abnormality or dilation within the ureter or dilation within the bladder or kidney. However, in a younger child, the gold standard test for investigating VUR is called micturating cystourethrogram (MCUG). In this situation the child who is under the age of 1 year old, a catheter is inserted into bladder. The bladder is then filled a contrast material and x-ray, which is able to show whether there is any reflux present. If the x-ray is able to determine if there is reflux present, then there is a grade to be given.
06. How is reflux treated?
In the vast majority of children, the management is really focused on improving bladder function, emptying their bladder well and stop the infections. Therefore, the use of antibiotics is used in first line treatment in order to prevent urinary tract infections and maintain kidney function. If the child continues to get ongoing urinary tract infections despite being treated unsuccessfully, there can be then need for surgery. However, most children do not require surgical intervention.
07. What surgery is required?
The vast majority of children can be treated with a keyhole operation. This consists of a procedure where a small camera is inserted into the bladder through the urethra. This enables us to see where the urethral opening is. A small amount of material is injected into the valve to improve the valve mechanism. This is a very successful day case procedure and has very low complications.
08.What other surgical operations are available?
In the past, a very common operation called ureteric re-implantation was performed. This is a basic procedure where the bladder is opened, the ureters are disconnected from the bladder and then re-implanted and reattached in a new fashion to make a longer tunnel which recreates a functioning valve. The child will require staying in hospital for a few days following the surgery. In general, this operation is required less frequently than it was historically in the past and the vast majority can be treated with endoscopic method.
Hydronephrosis is dilatation of part of the kidney. Generally, it’s due to the fact there is slow or sluggish drainage in part of the kidney, down to the ureter. The condition usually occurs in the womb and it is sometimes detected before a baby is born. However, hydronephrosis symptoms are sometimes only recognised during investigations into urinary problems that are performed after a baby is born.
Symptoms of Hydronephrosis
Hydronephrosis symptoms aren’t usually obvious, so the condition is usually detected during investigations that are being done for other reasons. When hydronephrosis occurs in the womb, it is often detected during the routine anomaly scan that is performed at around 20 weeks. Hydronephrosis symptoms can also be detected in babies after the birth if doctors are performing scans to investigate the causes of urinary symptoms.
Most children do not present with any signs or symptoms for unilateral hydronephrosis. Historically the most common symptom for hydronephrosis is in fact a urinary tract infection. The symptoms of urinary tract infection in the older child can consist of high temperature, pyrexia and dysuria (pain when voiding). There could be cloudy urine, blood in the urine and pain in the child’s side or their back. Younger babies will not necessarily present with clear symptoms and when they develop a urinary tract infection they can have high temperature, irritability and failure to thrive. The hydronephrosis can then be detected when an ultrasound scan is performed to investigate the causes of the urinary tract infections.
Presently a vast majority of children are diagnosed with hydronephrosis on fetal scans. At present, the 20 weeks scan can be useful for detecting hydronephrosis and this frequently means there may be further ultrasound scans required in pregnancy. This can occur at approximately 1 – 2% of all pregnancies. Hydronephrosis won’t usually cause any problems for the baby or the mother during pregnancy. However, additional monitoring may be recommended and treatment may be required after the baby is born.
In the occasion of unilateral hydronephrosis, the baby will require an ultrasound scan after the child is born. In certain situations, preventative antibiotics which will decrease the severity of infections will potentially be of benefit. In this situation your child will need some further investigations to see what is going on.
It is important for hydronephrosis symptoms to be investigated carefully in order to identify the cause of the problem. Untreated hydronephrosis could increase the risk of urinary tract infections and it might affect the functioning of the kidneys. The kidneys could be damaged if the problem is left untreated.
Causes of Hydronephrosis
Hydronephrosis happens when urine collects inside the kidneys. The kidney will then swell up. The increase in size can be detected on an ultrasound scan. Urine can build up inside the kidney if it isn’t able to make its way to the bladder or if it returns back up the ureter.
The kidneys are the organs that produce urine. Most people have two kidneys. Each kidney is connected to the bladder through a tube known as a ureter. The bladder collects the urine from the kidneys and stores it until it can be eliminated from the body by urination. The tube that carries urine from the bladder and out of the body is called the urethra. Valves normally prevent the urine from moving back up towards the kidneys.
Hydronephrosis can happen for a number of different reasons. In most cases, the problem will only affect one of the kidneys. This is known as unilateral hydronephrosis and it won’t usually cause serious issues as the unaffected kidney will still be able to function normally. However, in some cases, both kidneys can be affected. This can be more serious if the body is not able to eliminate waste by producing urine efficiently enough.
The most likely causes of hydronephrosis in babies are:
• Blockages in the urinary tract. The blockage could be between the kidney and ureter, between the bladder and the ureter or in the urethra that leads out of the bladder.
• Ureteric duplication, which happens when there are two ureters connecting one of the kidneys to the bladder. The lower end of one of these ureters is then likely to be blocked. This condition happens in about 1% of babies.
• Multicystic dysplastic kidney (MCDK), which occurs when one of the kidneys fails to form correctly. The non-functioning kidney contains large numbers of cysts.
• Vesico-ureteric reflux (VUR), which occurs when the valve where the ureter connects to the bladder doesn’t work properly. It isn’t able to stop urine from moving back up the ureter towards the kidney.
Surgery of Hydronephrosis
Hydronephrosis can be diagnosed using ultrasound scans to check for kidney enlargement and MAG3 scans to get more detailed pictures of the kidneys. MAG3 scans use a special isotope to check on the kidney’s structure and function. The isotope can be traced as it passes through the kidneys.
Depending on the ultrasound scan and MAG3 findings and their symptoms, some children will require surgery to improve drainage of their kidney. Usually procedure which is preformed is a pyeloplasty. This is an operation to remove the small narrowed area between the pelvis of the kidney and the ureter which is called the pelvi ureteric junction (PUJ). Once this is removed, two tubes are joined back together and a small stent is left internally. This is removed a number of months later.
If the hydronephrosis symptoms are caused by something other than a blockage in the ureter, then other approaches to treatment may be recommended. For example, if the condition is linked to a multicyclic kidney, it may be sufficient to monitor the kidney to see if it shrinks by itself. However, if the kidney grows too large or starts raising the blood pressure, it may need to be removed. As long as the other kidney is functional, this should not cause any problems for the child’s health and wellbeing.
Antibiotics can also be prescribed to tackle urinary tract infections linked to hydronephrosis. However, the problem can return if the underlying cause is not addressed.
Hydronephrosis Post-Operation
Most children are able to go home the following day and some children will require two nights in hospital. In general, if the child is already on preventive antibiotics, they will remain on antibiotics until the stent is removed. A vast majority of children are very comfortable following the surgery. Once the stent is removed, the child will have a number of ultrasound scans and further MAG3 the following year to ensure their systems are working at the maximum capacity. After this, most children do not require further follow-up.
As long as hydronephrosis is detected and treated before the kidneys have been damaged, it won’t usually cause any long-term health problems. If the condition is severe enough to damage the kidneys then they can become unable to function properly. Kidney failure can be very serious if both of the kidneys are affected so it is essential for hydronephrosis to be monitored and treated correctly.
Hydronephrosis FAQs
1.What is the cause of hydronephrosis?
Hydronephrosis is very commonly seen on antenatal scans. A vast majority of people’s prenatal scans, one kidney can appear larger than normal. Normally this resolves in its own time and is due to alterations in either the flow or anatomy of the kidney.
Hydronephrosis can also be caused by stones or previous surgery and can be caused by other rare conditions. A small number of children have a narrowing of the tube leading from the kidney. This is called a pelvi ureteric obstruction. There can also be a small kink and blockage of that area or there can be reflux, which allows urine to go back from the bladder to the kidney
2. Does this need to be monitored or watched?
If hydronephrosis symptoms are detected in the womb then additional ultrasound scans are usually recommended to monitor the condition during the rest of the pregnancy. If the kidney grows too large, some of the fluid may need to be drained before the baby is born. However, in most cases the pregnancy and birth can proceed as normal, without any additional treatment.
The baby will continue to be monitored with ultrasound scans and other tests after the birth. These tests will also be recommended if hydronephrosis is detected after birth. The results will determine when and if further action needs to be taken. Surgery may be recommended if there is a blockage in the ureter or if the kidney has become very enlarged.
Monitoring is also recommended for at least a year after surgery to correct hydronephrosis. Ultrasound scans and MAG3 tests will be able to confirm that the treatment has been successful.
3. What are the signs and symptoms?
Most children do not present with any signs or symptoms for unilateral hydronephrosis. Historically the most common symptom for hydronephrosis is in fact a urinary tract infection. The symptoms of urinary tract infection in the older child can consist of high temperature, pyrexia and dysuria (pain when voiding). There could be cloudy urine, blood in the urine and pain in the child’s side or their back. Younger children will not necessarily present with clear symptoms and when they develop a urinary tract infection they can have high temperature, irritability and failure to thrive without any clear symptoms relating to the kidney. If your child experiences severe or recurring urinary tract infections then an ultrasound scan may be performed to check for blockages or other issues with the urinary system. The scan can then reveal hydronephrosis symptoms such as an enlarged kidney.
4. How is it diagnosed?
Presently a vast majority of children are diagnosed with hydronephrosis on fetal scans. At present, the 20 weeks scan can be useful for detecting hydronephrosis and this frequently means there may be further ultrasound scans required in pregnancy. This can occur at approximately 1 – 2% of all pregnancies. However, hydronephrosis symptoms can also be detected after the baby is born. This usually happens when ultrasound scans are performed to check on the kidneys due to recurring urinary tract infections or other issues.
5. Will my child need further tests after they are born?
In the occasion of unilateral hydronephrosis, they will require an ultrasound scan after the child is born. In certain situations, preventable antibiotics which will decrease the severity of infections will potentially be of benefit.
6. What happens if my child has hydronephrosis in both kidneys?
In this situation your child will need some further investigations to see what is going on. They will require at least an ultrasound scan of the kidneys and a micturating cystourethrogram (MCUG). They will also require a nuclear medicine which is called a DMSA scan which will be able to determine the presence of scars.
The vast majority of children will not require a MCUG and merely require an ultrasound scan. Some children require both an ultrasound scan and a nuclear medicine test.
7. Will my child require an operation?
Depending on the ultrasound scan and MAG3 findings and their symptoms, some children will require surgery to improve drainage of their kidney. Usually procedure which is preformed is a pyeloplasty. This is an operation to remove the small narrowed area between the pelvis of the kidney and the ureter where the pelvi ureteric junction is. Once this is removed, two tubes are joined back together and a small stent is left internally. This is removed a number of months later.
8. What happens after the operation?
Most children are able to go home the following day and some children will require two nights in hospital. In general, if the child is already on preventive antibiotics, they will remain on antibiotics until the stent is removed. A vast majority of children are very comfortable following the surgery. More details are given at that stage.
9. What follow-up will my child need?
Once the stent is removed, the child will have a number of ultrasound scans and further MAG3 the following year to ensure their systems are working at the maximum capacity. After this most children do not require further follow-up.
