eMedicine Specialties > Pediatrics: Surgery > Urology
Pediatric Urologic Gynecology
Updated: Aug 15, 2006
Introduction
The wide spectrum of anomalies of female embryogenesis result in problems related to the development of the urinary and genital tracts. Many of the clinical disorders observed in girls and young women that appear to involve the genitalia alone may be the harbinger for related urinary tract disorders. Abnormalities that occur in infancy may be easy to recognize secondary to an abnormal finding on antenatal ultrasonographic studies or physical examination in the newborn period; however, many urogenital malformations are elusive and may become evident only when a clinical problem arises.
The most common urogynecologic disorders prompt childhood evaluations that focus on problems of urinary continence and introital abnormalities. Interlabial masses, often included in the differential diagnosis of urinary incontinence, as well as difficulties with appropriate sex identification in genetic and phenotypic females are discussed. Because congenital abnormalities result from abnormal embryogenesis, beginning with a brief overview of healthy female embryology is appropriate.
For excellent patient education resources, visit eMedicine's Children's Health Center, Cancer and Tumors Center, and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Bedwetting, Bladder Cancer, and Bladder Control Problems.
Female embryology
Congenital abnormalities commonly involve the urinary and genital tracts. An understanding of normal embryogenesis is a prerequisite for understanding congenital abnormalities. Marshall in 1978 and Stephens in 1996 have provided a detailed discussion of the embryology of the lower urinary tract. The divergence of normal sexual differential into male and female phenotypes begins in the ninth week of gestation. If no Y chromosome is present, the ovaries develop while the testis and Sertoli cells do not. As a result, the wolffian system regresses (absence of androgen production) and the müllerian ducts form the fallopian tubes, uterus, and proximal part of the vagina (absence of müllerian-inhibiting factor).
Urinary incontinence in girls
Urinary incontinence in females may result from functional or neurogenic causes or may be secondary to congenital abnormalities of the lower urinary tract. The most common cause of severe urinary incontinence in children is related to a neurologic deficit. The leading causes of neurogenic incontinence include myelomeningocele (spina bifida), sacral agenesis, and vertebral or spinal cord lesions. In these conditions, changes within the spinal cord may occur over time and mandate careful evaluation and close follow-up.
All children who present with urinary incontinence should undergo a careful history, physical examination, and urinalysis. The timing of incontinence may offer clues to potential diagnoses. For example, diurnal and nocturnal incontinence, or incontinence preceded by urgency, squatting behaviors, or both, have different clinical implications. Because bowel and bladder function are sometimes linked, a history of hard painful stools, encopresis, and infrequent bowel movements, all of which may indicate constipation, should be sought.
The physical examination should focus on the abdomen, external genitalia, back, and anus. The integrity of sacral cord function is important because deficits may indicate occult neurogenic bladder disorders. Anal sphincter tone provides information regarding the functional status of the sacral cord and roots. Finally, urinalysis is essential in the evaluation to assess for infection, renal concentrating defects (early morning specific gravity <1.022), hematuria, proteinuria, and glucosuria, which may suggest diabetes. Chronic nighttime wetting, polyuria, or nocturia may indicate renal failure or diabetes, and these symptoms require thorough medical evaluation.
Incontinence may be broadly divided between that which requires surgical intervention and that which requires medical or behavioral therapies. In general, incontinence that is related to primary nocturnal enuresis (PNE) or infrequent voiding tends to resolve with time and does not require surgery. The following sections address the clinical presentation, evaluation, and treatment of lower urinary tract abnormalities that are associated with urinary incontinence in girls.
Functional Causes of Urinary Incontinence
Functional causes of urinary incontinence include PNE, dysfunctional voiding, and pseudoincontinence (eg, vaginal voiding).
Nocturnal enuresis
PNE is defined as persistent night wetting in individuals older than 5 years. It occurs in approximately 20% of 5-year-old children, and the incidence decreases with age. While PNE is more common in boys, daytime wetting, urinary urgency, and frequency are more common in girls. The diagnosis and treatment of nocturnal enuresis is multifactorial, depending on the pathophysiology and psychologic analysis of the patient. Treatments using desmopressin (1-deamino-8-arginine-vasopressin [DDAVP]), imipramine, bedwetting alarms, or combinations of these therapies are often successful. Daytime symptoms, such as enuresis, urgency, and frequency, may be treated with anticholinergic medications.
Dysfunctional voiding
Children with dysfunctional voiding have difficulty relaxing their pelvic floor musculature. This musculature comprises the external urethral sphincter. Also, the rectum traverses through the pelvic floor musculature. As a result, daytime and nighttime wetting, urinary frequency or infrequency, urgency, urinary tract infections, and constipation or encopresis are common. Having patients and their families keep an elimination diary to ascertain the child's specific toilet habits is useful. For example, many parents are not aware that their child has constipation unless specifically queried as to the frequency and caliber of the stool. Simple treatment of constipation with stool softeners (eg, mineral oil, Kondremul) or laxatives (eg, Miralax, Dulcolax) permits better overall toilet behavior. Voiding dysfunction may be treated by behavior modification or pharmacologic agents and does not require surgical intervention.
Vaginal voiding
Vaginal voiding is often confused with true urinary incontinence (see Image 1). Micturition into the vagina results in leakage when the child stands upright, which allows efflux of urine from the vaginal vault. Simple maneuvers that better direct the urinary stream, such as separating the legs further apart during voiding and waiting a few minutes after micturition to allow efflux into the toilet, usually solve the problem.
Congenital Abnormalities That Cause Incontinence
Congenital anomalies may cause incontinence by interfering with the function of the sphincter mechanisms, the storage function of the bladder, or by anatomically bypassing normal sphincter mechanisms. Imaging studies are essential to define the anatomic abnormalities causing the incontinence.
Renal and bladder ultrasonography (RBUS) and voiding cystourethrography (VCUG) are usually the first studies obtained. RBUS is excellent in assessing for duplication anomalies and in revealing hydronephrosis. Hydronephrosis may be secondary to vesicoureteral reflux (VUR), an ectopic ureter, or a ureterocele, which is often visible on bladder images (see Image 2). VCUG is the most commonly used method to assess for VUR. The plain abdominal scout radiograph of the VCUG can be used to assess for bony abnormalities and for the presence of fecal impaction.
If significant hydronephrosis is present or if the kidneys appear echogenic or scarred, renal scintigraphy (renal scan) can be obtained to determine differential function. If the anatomy or function is still unclear, gadolinium-enhanced magnetic resonance urography (MRU) can be useful (see Image 3). Urodynamic studies often are useful in detecting sphincteric, storage, and urinary flow abnormalities and are essential in all patients with neurogenic incontinence. The treatment goals of congenital abnormalities of the female urogenital tract are restoration of physical appearance and function, preservation of renal function, and achievement of manageable urine storage and continence.
Abnormal Storage
Bladder exstrophy and female epispadias
The incidence of bladder exstrophy is 1 per 30,000 live births and is less common in females than in males. It is part of a continuum of developmental anomalies that result from a persisting cloaca or an abnormally large cloaca that does not retract normally toward the perineum. Bladder exstrophy is a more severe anomaly, while epispadias is a less severe variant of the exstrophy-epispadias complex. The initial management of bladder exstrophy involves covering the exposed bladder with a nonocclusive dressing (ie, plastic food wrap) to protect the bladder plate.
To prevent unnecessary trauma, ligating the umbilical cord with silk ties rather than a plastic or metal clamp is best. Some children with bladder exstrophy develop functional bladder capacities, while others go on to develop small and poorly compliant bladders. The reason for this is not completely understood. The surgical management of bladder exstrophy involves bladder closure within the first days of life. Bladder enhancement and bladder diversion are surgical options later. Bladder neck reconstruction may be performed at the time of bladder closure or in a staged fashion. Continence rates range from 43-87%.
Female epispadias (see Image 4) may result in variable presentation, depending on the severity of the urethral defect. In complete epispadias, incontinence is caused by (1) a foreshortened and widened urethra, (2) a partially absent external urethral sphincter, and (3) a poorly developed bladder neck. Treatment is directed at reconstruction of these deficient structures and at ureteral reimplantation proximal to the reconstructed bladder neck region. Persistent incontinence may be treated with collagen and/or dextranomer hyaluronic acid (Deflux) implantation at the bladder neck.
Cloacal exstrophy
The incidence of cloacal exstrophy (see Image 5) is 1 per 200,000 live births and is much less common in females. It is the most severe manifestation of developmental abnormalities related to the exstrophy-epispadias complex. In cloacal exstrophy, the bladder plate is divided in half by the hindgut. The ileum enters and intussuscepts into the middle of the hindgut, creating an "elephant truck" deformity. This and other associated anomalies, including omphaloceles, spinal dysraphism, and orthopedic anomalies, mandate a multidisciplinary approach to the reconstruction of bladders in these children. The treatment of storage abnormalities of the bladder usually involves bladder augmentation with intestinal segments. Clean intermittent catheterization (CIC) may also be required to maintain urinary continence.
Myelomeningocele
In the pediatric population, myelomeningocele is a common cause of neurogenic bladder, leading to problems with urinary storage, sphincteric function, and elimination. In the United States, the prevalence is approximately 1 per 1000 births. CIC in conjunction with anticholinergic medications has led to a dramatic improvement in the management of patients with myelomeningocele. The use of CIC has been shown to promote continence, preserve renal function, and decrease the incidence of symptomatic pyelonephritis. In 1981, McGuire and coworkers determined that a leak point pressure (LPP) greater than 40 cm H2O was predictive of renal deterioration over time. CIC serves to keep bladder pressure low, avoiding high LPP.
Abnormal Sphincter
Anatomic abnormalities may impede normal development of the bladder neck. Incompetence of the bladder neck may result in primary urinary incontinence and is observed in conditions such as female epispadias, urogenital sinus, bilateral ureteral ectopia, and ectopic ureteroceles. Conservative measures to improve sphincteric function are limited, and a surgical approach is needed. The surgical options focus on creating an increase in bladder outlet resistance or on creating a new sphincter mechanism.
Urogenital sinus anomalies
The persistence of the urogenital sinus may result in the urethra emptying into the vaginal vault. This may not be readily apparent unless the urethra is not observed during attempts at catheterization. Infants may present with a dilated vagina, possibly resulting in an abdominal mass, if the posterior lip of the hymen causes partial obstruction at the orifice of the urogenital sinus. Retained urine in the vagina (urocolpos) and uterine canal may increase to enormous volumes. Drainage of urine with vaginal catheterization followed by vaginography showing contrast within the cervical canal and uterus, and possibly into the peritoneal cavity, is diagnostic. Treatment involves endoscopic division of the posterior hymenal lip. Further reconstructive surgery is usually required.
Duplicated ectopic ureters
An ectopic upper pole ureter may join the lower end of the remnant mesonephric duct system comprising Gartner ducts. These ureters are associated with nonfunction of the associated renal moiety and may result in the formation of cystic dilatation of the Gartner duct with eventual rupture of the cyst and drainage into the vaginal opening. Drainage of fluid or pus into the vagina prompts further investigation. Renal and pelvic ultrasonography may show a dilated or abnormal upper pole renal moiety, and a cystic structure may be observed in the pelvic or vaginal area. CT scanning or MRI studies are helpful in further delineating the anatomy, while findings on retrograde fluoroscopic studies are diagnostic if the often-elusive ectopic orifice can be identified.
The appropriate treatment of ectopic ureters depends on whether the ureter is ectopic or bilateral and whether it drains into the genital or urinary tracts. Ectopic ureters to the genital tracts may be treated by simple upper pole nephrectomy, while ectopia to the urinary tract usually involves ureterectomy in addition to heminephrectomy in order to prevent postoperative urinary reflux and infection.
Bypass of Sphincter Mechanism
In instances where the bladder neck and sphincter mechanism have developed normally, urinary incontinence may develop as a result of ureteral ectopia distal to the continence mechanism. The most common cause for this abnormality is ectopic ureters. Incontinence may not be purely secondary to a bypass mechanism because abnormal urethral development may contribute to poor urinary control.
Bilateral single ectopic ureters
Ectopic ureters result when a ureteric bud develops more cranially than usual from the mesonephric duct. In females, ectopic ureters usually open into the urethra, the vestibule, or the vagina. Incontinence is a common symptom in girls with an ectopic ureter. Bilateral ectopic ureters may enter the urethra just distal to the bladder neck. Because of the inadequacy of urethral length associated with this condition, incontinence may be observed. In single ectopic ureters, a cyclic VCUG may demonstrate vesicoureteral reflux when the bladder neck relaxes upon micturition; reflux is not often demonstrated during bladder filling when the bladder neck is in a contracted state.
Treatment involves ureteral reimplantation and bladder neck reconstruction for bilateral single ectopic ureters. Treatment for duplicated ectopic ureters includes upper pole partial nephrectomy and lower pole reimplantation. In unsuccessful cases, use of a continent catheterizable channel (eg, appendicovesicostomy) or continent urinary diversion may be considered.
Interlabial Masses
Masses within the vagina that are present in infants and young girls are generally referred to as interlabial masses. While many of these lesions arise within the introitus, those arising in the urethra or bladder must be recognized to afford proper management. Many patients with masses within the vaginal area report leakage of fluid (eg, urine, pus, transudate). A complete physical examination of the introitus is part of the evaluation of urinary incontinence.
Skene glands (paraurethral glands)
These tubular glands arise from the urethral epithelium and are the counterparts to the male prostatic glands. In females, Skene glands may end up in the urethral meatus and hymen. Cysts (tense, yellow, thin-walled) partially arising within the urethral meatus but mostly external to it may resemble a bulging hymen associated with hydrometrocolpos or a prolapsing ureterocele.
Bartholin glands
The major vestibular glands of Bartholin arise from the urogenital sinus and open into the vestibule on either side of the hymen. The main glands lie against the ischiopubic ramus deep to the bulbospongiosus muscle and cavernous tissue. Blockage of the main ducts of the Bartholin glands may lead to cystic dilatation in females of any age, but they rarely become infected prior to puberty.
Prolapsed ureterocele
A ureterocele is a dilated distal ureter within the detrusor muscle that may extend beyond the bladder neck (ectopic ureterocele). These ureters are often associated with an upper pole renal moiety of a duplicated collecting system. An interlabial mass may be identified if the ectopic ureterocele extends through the urethral meatus. Treatment is directed at ureterocele excision, ureteral reimplantation, and possible bladder neck reconstruction.
Hydrocolpos and hydrometrocolpos
Circulating maternal estrogen in the newborn girl may result in an increase in the production of cervical mucus. Hydrocolpos and hydrometrocolpos results when mucus collects in the vaginal vault and uterus, respectively. In these instances, the vaginal orifice may be blocked secondary to an imperforate hymen, a urogenital sinus, an atretic rectocloacal canal, or vaginal/uterine atresia. Hydrometrocolpos, by virtue of its abdominal extension, may compress the urethra, rectum, and ureters. Treatment of hydrocolpos and hydrometrocolpos secondary to a normally located imperforate hymen may involve simple perforation of the hymen in the newborn nursery. If the hymen appears thickened, incision under general anesthesia may be required. Higher obstruction involves a more formal approach to treat the associated urogenital abnormalities of vaginal atresia, urogenital sinus, or a rectocloacal canal.
Urethral prolapse
Eversion of the distal urethral mucosa through the urethral meatus results in a circumferential interlabial lesion (see Image 6). These lesions may be painful, may bleed, or they may weep serosanguinous fluid, prompting medical attention, but they do not lead to urinary incontinence. Examination reveals edematous or necrotic tissue exiting the urethral meatus. Visualization of the urethral meatus in the center of this tissue helps to distinguish this lesion from neoplasms of the vagina or bladder. A prolapsed urethra associated with mild edema without necrosis or significant pain may be treated conservatively with sitz baths and estrogen cream over a 2- to 3-week period. More significant lesions should be excised.
Rhabdomyosarcoma of the vagina
Patients with rhabdomyosarcoma of the vagina and bladder may present with a grapelike interlabial lesion associated with vaginal bleeding. Because of the propensity to spread, a complete endoscopic and radiographic evaluation is indicated to confirm the diagnosis and to rule out local extension and distant lesions. Primary chemotherapy has resulted in better bladder salvage and can cure metastatic disease. Surgical excision with or without radiation therapy is reserved for postchemotherapy biopsy-proven residual masses.
Disorders of the Female Genitalia
Intersex disorders
A complete description of the array of intersex disorders is beyond the scope of this article; however, urologists and gynecologists must be familiar with the more common intersex disorders whereby gender assignment and rearing is along female lines. These conditions include normally appearing girls who are genetically male (male pseudohermaphrodites) and genetic females appearing as males (female pseudohermaphrodites).
Female pseudohermaphrodites are genetic females (XX karyotype) but may appear as males without testes. The most common cause of female pseudohermaphroditism is congenital adrenal hyperplasia (21-hydroxylase deficiency in >90%) (see Image 7). In this disorder, the absence of 21-hydroxylase results in the overproduction of androgens and results in a wide spectrum of genital abnormalities, ranging from mild masculinization of the clitoris (clitoromegaly) to complete masculinization. The labioscrotal folds are rugous and hyperpigmented, producing the physical appearance of severe hypospadias with cryptorchidism; however, in all cases, the internal female anatomy is normal. After the diagnosis is established, surgical treatment involves feminizing genitoplasty (eg, reduction clitoroplasty, vaginoplasty, labioplasty).
Male pseudohermaphrodites are genetic males (XY karyotype) but may appear as females. Testicular feminization is the most common cause of male pseudohermaphroditism. Testicular feminization results from androgen insensitivity. Suspect the diagnosis in all girls with inguinal hernias. The hernia sacs may be found to contain testes. Always suspect the diagnosis of male pseudohermaphroditism in adolescent girls with normal development and primary amenorrhea. Development and sexual identity is female. Testes left in place produce testosterone, which is converted to estradiol. While this estradiol allows for spontaneous breast development, generally the testes are removed at the time of diagnosis because of the risk for gonadoblastoma. Girls who have undergone prepubertal orchiectomy should receive estrogen replacement therapy.
Vaginal agenesis and the Mayer-Rokitansky syndrome
Agenesis of the vagina in genetic females may be accompanied by various other defects in the genitourinary tract. Most patients present in adolescence with amenorrhea or pain, but young girls may also present with urinary tract infection or hydrocolpos. Genital defects include the spectrum of vaginal agenesis alone to agenesis of the uterus and fallopian tube. These genital defects are associated with (ipsilateral) renal agenesis. Some patients presented after urethral intercourse leading to stress urinary incontinence. Treatment of the Mayer-Rokitansky syndrome includes vaginoplasty or neovaginal reconstruction with bowel.
Urinary Tract Reconstruction
Lower urinary tract reconstruction
Since 1950, bowel segments have been used to entirely replace a diseased or dysfunctional bladder. The current success in reconstruction of the lower urinary tract reflects the improved understanding of the physiologic principles involved in bladder and urethral function. Spontaneous voiding can occasionally be achieved with an abnormal lower urinary tract provided the pressure gradient between the bladder and distal urethra are low. Therefore, even in cases in which the bladder is replaced in part (intestinal cystoplasty) or entirely (neobladder), patients may still be able to empty their bladders satisfactorily. Many patients require bladder neck reconstruction to achieve continence, and most patients require CIC.
Continent reconstruction of the lower urinary tract is often desired in the setting of congenital or acquired anomalies of the outlet and the bladder. The early work of Hendren, Mitrofanoff, and others has led to surgical approaches that produce better reservoir function and a continent outlet. Continent urinary diversion encompasses 3 interrelated but independently functioning components, which include a channel by which urine is conducted to the skin, a reservoir or pouch, and a mechanism by which continence is achieved. A host of tissues is available to the reconstructive surgeon.
The flap valve principle for continence dictates that a portion of the continence channel must be fixed on the inner wall of the reservoir. This is the same principle by which ureteral tunneling in the bladder muscle prevents reflux during voiding. In general, a length-to-diameter ratio of 5:1 of the continence structure is required. This is the case whether the structure is ureter, ileum, or appendix.
The Mitrofanoff principle of continent reconstruction describes a supple catheterizable structure (eg, ureter, appendix) implanted into the inner wall of the reservoir to create a flap valve continence mechanism. The most popular form of flap valve construction for urinary continence is the use of appendix implanted into the bladder or reservoir (appendicovesicostomy). The small stoma may be concealed within the umbilicus. Assurance of complete bladder emptying is essential because this type of continence channel is very effective in its ability to withstand very high intraluminal pressure. In the noncompliant patient, pouch rupture or upper tract injury may result from failure to regularly empty the reservoir.
Urinary tract reconstruction and pregnancy
Keep in mind future pregnancy when reconstructing the genitourinary tract. Pregnancy may be complicated and requires care by the obstetrician and urologist. Renal obstruction and incontinence may result as the uterus enlarges. Neobladder reconstruction has a good outcome, but chronic bacteriuria is frequent and occasionally requires an indwelling catheter in the third trimester. Likewise, when suprapubic catheterizable continent stomas have been constructed, indwelling catheterization through the stoma during the third trimester may be needed to avoid serious urinary tract infections.
Successful pregnancies and deliveries have been reported after continent and loop urinary diversions. Obstetric indications should guide the mode of delivery, although abdominal delivery has been successful in most cases. Alternatively, if the bladder neck has been reconstructed, performing a caesarean delivery to avoid damage to the bladder neck reconstruction is usually advisable. The urologist should be available to the obstetric team for consultation if caesarean delivery is deemed necessary, especially if a bladder augmentation with bowel has been performed, in order to avoid injury to the vascular pedicle of the bowel segment.
Multimedia
 | Media file 1: Voiding cystourethrography (VCUG) showing vaginal reflux (arrow) during the voiding phase of the study. |
 | Media file 2: Renal/bladder ultrasound showing cystic structure in the expected area of the left ureteral orifice consistent with a ureterocele. |
 | Media file 3: Magnetic resonance urography (MRU) showing severe left hydroureteronephrosis resulting from an ectopically inserted ureter. |
 | Media file 4: Female epispadias. |
 | Media file 5: Cloacal exstrophy. |
 | Media file 6: Urethral prolapse (arrow). |
 | Media file 7: Female pseudohermaphroditism. Note the clitoromegaly and small introitus. |
Keywords
pediatric urologic gynecology, incontinence, introital abnormalities, nocturnal enuresis, interlabial masses, dysfunctional voiding, vaginal voiding, bladder exstrophy, cloacal exstrophy, myelomeningocele, female epispadias, urogenital sinus anomalies, duplicated ectopic ureters, bilateral single ectopic ureters
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Further Reading
Keywords
pediatric urologic gynecology, incontinence, introital abnormalities, nocturnal enuresis, interlabial masses, dysfunctional voiding, vaginal voiding, bladder exstrophy, cloacal exstrophy, myelomeningocele, female epispadias, urogenital sinus anomalies, duplicated ectopic ureters, bilateral single ectopic ureters
