Part 24. Urologic disorders in infants and childhood
Part XXIV. Urologic Disorders In Infants And Children
Chapter 491. Congenital Anomalies & Dysgenesis Of The Kidney
;
*»ýÈÄ 1ÀÏ
³» voidingÀÌ
¾øÀ¸¸é underlying anatomic
abnormality °Ë»ç
;
Ãâ»ý½Ã urine
1) pH 5¡7
2) osmolality : 60¡600mOsm/Kg
(mmol/Kg) H2O
3) many epithelial cell
4) RBC : °£È¤ Á¸Àç
5) *WBC
: Ùí
6) culture : sterile
7) glucose & protein : trace amount
Renal agenesis(aplasia)
Bilateral Agenesis
;
incidence : 1/,3000
;
°á°ú : stillborn fetus
#
¡Ø96°´
Potter phenotype
; oligohydramnios¿¡ ÀÇÇØ ¹ß»ýÇϴ Ư¡ÀûÀÎ ÀÓ»óÁõ»ó
-
wide separated eyes
-
epicanthic folds
-
receding chin
-
limb anomalies
-
hypoplastic lungs
; causes
-
renal agenesis, cystic renal dysplasia, obstructive uropathy, infantile
polycystic kidney, renal hypoplasia, medullary dysplasia
#
*DDx of agnesis & aplasia
; aplasia
-
extreme form of dysplasia
-
*presence of nonfunctional tissue
capping a normal or abnormal ureter
2)
hereditary renal dysplasia
: autosomal dominant
50¡90%ÀÇ
penetrance
´Ù¾çÇÑ
expression
anorectal,
cariovascular, skeletal abnormality
4. Áø´Ü
1) maternal ultrasound (2nd trimester)
: oligohyramnios
bladderÀÇ
nonvisualization
absent
kidney
5. 1°³¿ù ³» deathÀÇ ¿øÀÎ
: uremia or pulmonary
insufficiency
Unilateral Renal Agenesis
;
´Ù¸¥ °Ë»çµµÁõ ¿ì¿¬È÷ ¹ß°ßµÇ´Â °æ¿ì°¡ ´ëºÎºÐ
;
*single umbilical artery ÀÖÀ»
¶§ ¹Ýµå½Ã
ÀǽÉ
;
absence of ureter, ipsilateral bladder, hemitrigone
contralateral
kidney : Ãâ»ýÈÄ compensatory hypertrophy
associated
anomaly
1)
genitourinary aystem : 40%
2)
skeletal system : 30%
3)
cardiovascular system & gastrointestinal system : °¢°¢
15%
4)
CNS & respiratory system : °¢°¢ 10%
incidence
1)
1/1,000 live births
;
*male > female
;
*left > right
¢¾ Mayer-Rokitansky
Syndrome
; unilateral renal agenesis
& vaginal atresia or agenesis
vas
defensÀÇ agenesis, seminal vesicle cyst
Anomalies In Shape And Position
ascent
& rotationÀÇ ºÒ¿ÏÀü Fig 491-2
¡æ renal ectopia or
nonrotation ¹ß»ý
#
Horseshoe Kidney
; ½ÅÀåÀÇ
lower poleÀÌ Á߽ɼ±¿¡¼ À¶ÇÕ
; incidence - 1/500 birth
; *Turner syndromeÀÇ 7%
; *Wilm`s tumorÀÇ ¹ß»ýºóµµ°¡ 2¡8¹è
´õ ³ô´Ù
Hypoplasia
definition
: nephron¼ö°¡ °¨¼ÒÇÑ small kidney
;
*not inherited
unilateral
involvement
1)
segmental hypoplasia or Ask-upmark kidney : ÀϺΠinvolve
2)
entire involvement
3)
10¼¼ ¹Ì¸¸¿¡¼ hypertensionÀ¯¹ßÇÏ´Â
more common cause
bilateral
involvement
1)
chronic renal failureÀÇ Áõ»ó °¡Áü
2)
10¼¼ ¹Ì¸¸¿¡¼ ESRFÀÇ ÁÖ¿øÀÎ
3)
polyuria & polydypsia : common
4)
oligomeganephronia(rare form) : nephron¼öÀÇ ÇöÀúÇÑ °¨¼Ò & ÇöÀúÇÑ
hypertrophy
Dysplasia
1.
definition
: fetal kidneyÀÇ
structural diffentiationÀÇ »ó´çÇÑ º¯È·Î cyst, abnormal duct,
undefferentiated
mesenchyme, or cartilage°°Àº nonrenal element°¡ Á¸Àç
2. ¿øÀÎ
1) urinary tractÀÇ
intrauterine obstruction
: prune-belly
syndrome, ureterocele, urethral valve, ureteropelvic junction
¢¡ º¸Åë
bilateral & ESRF ¹ß»ý °¡´É
2) multicystic dysplasia
¨ç unilateral or
bilateral
¨è lower tractÀÇ
developmental anomaly or contralateral normal kidney¿Í °ü·Ã
¨é unilateral form
: nonfunctioning
flank mass
¢¡
renal tissue°¡ °ÅÀÇ ¾ø°Å³ª ÀüÇô ¾ø´Â cystic mass
hypertensionÀÌ »ý±â¸é Á¦°Å
¨ê bilateral form
: chronic renal
failure¿Í °ü·Ã ¢¡ ½ÉÇÑ °æ¿ì Potter syndrome¸¦ º¸ÀÓ
CHAPTER 492. Urinary Tract Infections
Prevalence And Etiology
#
newbornÀÇ symptomatic UTI
; 1.4/1,000
#
¡ÚRisk Factors
; variable markedly with age
& sex
; *uncircumcised male infant(<1yr)
; *female(>1yr)
; 7-11yr age
-
*¡ãcommon
age group (2.5%)
; sexually active female :
cystitis À§Çè Áõ°¡
; sexually active adolescent
male & female : urethritis ¹ß»ý °¡´É
#
Pathogens
; mostly colonic bacteria
; female
-
¡ÚE. coli(75¡90%) > Klebsiellla
> Proteus
; male over 1yr
-
*Proteus=E. coli in some report
- *G (+) cocci in another
report
; *Staphylococcus saprophyticus
-
both sex
Pathogenesis And Pathology
;
*in newborn
- *bloodstream or urethraÅëÇØ ħ¹ü
- *ÀÌÈÄ :
ascending infection
UTIÀÇ
susceptibility¿¡ °ü¿©ÇÏ´Â factor
1)
host factor : urethra cervical Ab (Ig A)
2)
bacterial adherence¿¡ °ü¿©ÇÏ´Â factor : P blood grup
phenotype
3)
immunosuppression, diabetes, urinary tract obstruction,
chronic granulomatous disease ½Ã Áõ°¡
infectionÀÇ
severity¿¡ °ü¿©ÇÏ´Â factor
1)
bacteriaÀÇ virulence
2)
anatomic factors
: ¡¤vesicoureteral reflux
+¡æ
vesical overdistention
-+¡æ
bladder wallÀÇ blood flow °¨¼Ò
+¡æ
infection¿¡ ´ëÇÑ bladderÀÇ
natural resistance °¨¼Ò
¡¤obstruction
¡¤urinary
stasis : bacterial multiplication
¡¤prisence
of calculi
Acute Bacterial Cystitis
1. Ư¡
: mucosal congestion, edema¿Í
petechiae, hemorrhage
¡æ
detrusor muscle hyperactivity
¡æ
bladderÀÇ functional capacity °¨¼Ò ¡æ
vesicoureteral reflux
2. cystitis cystica : chronic or
recurrent infection ÀÖ´Â °æ¿ì ¹ß»ý
Acute Pyelonephritis
#
¡ÚP1 blood group
; VURÀÌ ¾ø¾îµµ
ascending recurrent pyelonephritis
; *E. coli - specific binding to P1 antigen of epithelial cell
medulla¿Í
pelvis¿¡ acute inflammatory cell
infiltration ¡æ enlarged kidney
¡æ microabscess Çü¼º ¡æ
renal scar Çü¼º : chronic pyelonephritis
obstructionÀÖÀ¸¸é ´õ severe
Áï°¢ÀûÀÎ Ä¡·á : ¿ÏÀü
healing
Chronic Pyelonephritis
;
difficult to DDx
- medullary cystic disease,
ischemia, irradiation, analgesic abuse
* characteristic finding ;
cortical scar with underlying calyceal deformity
;
LM
- pathy with glomerular
fibrosis
- interstitial chronic
inflammation
-
tubuleÀÇ fibrosis & atrophy
;
*cortex º¸´Ù medulla°¡ susceptible
- high osmolality
-->
leukocyteÀÇ phagocytosis °¨¼Ò
#
reflux nephropathy
; renal scars in VUR children
; no history of UTI
; *flat papillae¿¡¼ ¹ß»ý
; *autoimmune response to Tamm-Horsfall protein
-->
play a role in development & progression of pyelonephritic scars
;
*90% of chronic pyelonephritis
- *VUR
¡Úreflux nephropathy or
chronic pyelonephritis
; ¡ã cause
of arterial hypertension in children
Urea-Spliting Organism : Proteus
;
*stone formation
- urea·ÎºÎÅÍ
ammonia»ý¼º ¡æ alkaline urine Çü¼º ¡æ
calcium phosphate, triple calcium, magnesium, ammonium phosphateÀÇ
precipitation°¡´É ¡æ calculi Çü¼º ¡æ
foreign body·Î ÀÛ¿ë ¡æ infection
ureteral
obstruction½ÃÀÇ infection
: septicemia, pyelonephrois, renal &
perirenal abscess formation
Xanthogranulomatous Pyelonephritis
1.
Á¤ÀÇ : giant cell°ú
foamy histiocyte°¡ ÀÖ´Â granulomatous inflammation
2.
renal mass, acute or chronic infection À¯¹ß
3.
predisposing factor
: renal calculi, obstruction,
Proteus or E. coliÀÇ infection
4.
treatment : nephrectomy
Clinical Manifestation
;
asymptomatic bacteriuria
- mostly
#
urinary tract infectionÀÇ symptom
1) infancy
;
*fever, weight loss, failure to
thrive, N/V, diarrhea, jaundice
2) children
;
urinary frequency, pain durine micturition, urinary incontinence asso. /c
urgency, bedwetting in a previously dry child, abdominal pain, foul smelling
urine
#
chronic or frequently recurrent cystitis
; daytime incontinence,
bladder instabilityÀÇ Áõ»ó
#
*hematuria
; *E. coli¿¡ ÀÇÇÑ hemorrhagic cystitis
#
acute pyelonephritis
; *fever, chill, flank or abdominal pain, tenderness, enlarged kidney
#
chronic pyelonephritis
; asymptomaticÀÌ Òý
; renal scar : arterial
hypertension
#
reflux nephropathy
;
15% of ESRF in childhood
#
sepsis
; common in infecion &
urinary tract obstruction
#
*hyperammonemia wih CNS symptom
; *Proteus UTI and urinary stasis & obstruction
Laboratory Data
#
culture
1) toilet trained children ;
midstream urine culture
¨ç ÀÇÀÇ
: single organismÀÌ 105 colonies/mL
¡æ UTI¿¡ 90% ÀÌ»óÀÇ
specificity°¡Áü
¨è ¡Ø87,94
low colony³ª¿À´Â °æ¿ì
;
overhydration, recent bladder emptying, antibiotic therapy
2) adhesive, sealed, sterile
collection bag
3) catheterized specimen
¨ç
infant : 5F polyethylene feeding tube
¨è
older children : 8F polyethylene feeding tube
4) suprapubic puncture
¨ç
full bladder ¸¸µé°í ½Ç½Ã
¨è
25 or 22 gauge needle »ç¿ë
¨é
pubisÀÇ midline¿¡¼
1 finger-breadth »ó¹æ, 10¡20¡Æ °¢µµ
¨ê ¡Ø87,94
false negative culture
;
unrecongnized antibiotic therapy, overhydration¿¡ ÀÇÇÑ dilution, antiseptic
solutionÀÇ contamination
#
urinalysis
1) pyuria : ³ó´¢ ¾øÀ̵µ
infection recur°¡´É
2) microscopic hematuria :
acute cystitis
3) urinary casts : renal
involvement
4) alkaline pH : Proteus
infection
#
upper & lower UTIÀÇ °¨º°
; acute renal infection
-
leukocytosis, neutorphilia, ESR & CRP Áõ°¡
-
Ab-coated bacteriaÀÇ detection
-
single dose antibiotic therapy¿¡ ´ëÇÑ ¹ÝÀÀ
-
´Ù¸¥ immunologic or biochemical test
/
urineÀ» ³óÃàÇÏÁö ¸øÇÏ´Â °æ¿ì
/
30%¿¡¼ ÀϽÃÀûÀÎ serum creatinine Áõ°¡
/
sepsis ¶§¹®¿¡ febrile infection½Ã
blood culture ÇÊ¿ä
; ¢¾Ç¥17-12(p722)
Imaging Studies
#
Renal Ultrasonography
; *Indication
¨ç
acute febrile infection½Ã hydronephrosis¿Í
renal, perirenal abscess¿Í °¨º°
¨è
antibiotic therapy¿¡ ´ëÇÑ ¹ÝÀÀÀÌ Áï°¢ÀûÀÌ ¾ÊÀ» ¶§
¨é
severely ill & toxic child
¨ê
serum creatinine level Áõ°¡
#
Technitium labeled 2,3dimercaptosuccinic acid(DMSA) or glucoheptanate renal
scanning
; *acute pyelonephritisÀÇ Áø´ÜÀÌ
ºÒÈ®½ÇÇÑ °æ¿ì
À¯¿ë
; parenchymal filling defect
-
pyelonephritis Áø´Ü °¡´É
-
chronic°ú acute °¨º°Àº ºÒ°¡´É
#
CT
; acute pyelonephritisÀÇ *definitive diagnostic
method
#
voiding cystourethrography
; *acute infectionÄ¡·áÈÄ ¾à 3ÁÖ° reflux Æò°¡À§ÇØ
½Ç½Ã
; ¢¾Indications
-
all males & females under 5yr with initial infection
-
older femaleat the time of second infection
; *female - radioisotopic VCUG
; male - radiographic VCUG
#
¡ÚVURÀÌ Á¸ÀçÇÑ´Ù¸é
-->
IVP with nephrotomography or radioisotope renal scanning ½Ç½Ã
; IVP
-
kidney size Æò°¡
-
°¡´ÉÇÑ calyceal blunting, ureteral
dilatation, renal scarringÀÇ detection
; DMSA or glucoheptanate
radioisotopic renal scan
-
*renal scarÀÇ detection
-
ÀåÁ¡
/ urographyº¸´Ù ´õ
sensitive
/ IV contrast mediaÀÇ
adverse effect Ùí
/ abdominal gas·Î ÀÎÇÑ
urographyÀÇ ÇØ¼® ¹æÇذ¡ ÀÖ´Â °æ¿ì
/ infant¿Í young child¿¡°Ô ƯÈ÷ À¯¿ë
Differential Diagnosis
1.
external genitaliaÀÇ inflammation
: yeast, pinworm¿¡ ÀÇÇÑ
vulvitis, vaginitis
´Ù¸¥
agent¿Í cystitsÀÇ °¨º°
2.
viral, chemical cystitis : history, urine culture
3.
hypoplastic, dysplastic kidney, vascular accident¿¡ ÀÇÇÑ small kidney¿Í
chronic pyelonephritisÀÇ °¨º°
: X-ray»ó À¯»ç
+¡æ º¸Åë vesicoureteral reflux Á¸Àç
*4. acute hemorrhagic cystitis
; E. coli
; *adenovirus type 11 & 21
-
male¿¡ Òý
- self-limited,
- ´ë°³ 4ÀÏ Á¤µµ Áö¼Ó
5.
eosinophilic cystitis
1) symptom
: hematuria, ureteral
dilatation
eosinophilic
mass¿¡ ÀÇÇÑ bladderÀÇ
filling defect
Treatment
#
acute cystitis½Ã pyelonephritis ¾È°¡°Ô
prompt treatment ÇÊ¿ä
; *symptomÀÌ severe ¡æ culteure¿Í
µ¿½Ã¿¡ Ä¡·á
½Ç½Ã
1) trimethoprim-sulfamethoxazole
-
7¡10ÀÏ
-
effective aganist E. coli
2) nitrofurantoin
-
5¡7mg/Kg/day, 3¡4
divided dose
- effective against Klebsiella-Enterbacter organism
3) amoxicillin : 50mg/Kg/day
;
symptomÀÌ mildÇϰųª Áø´ÜÀÌ ÀÇ½ÉµÉ ¶§
culture ÈÄ Ä¡·á ½Ç½Ã
;
culture °á°ú°¡ ºÒÈ®½ÇÇÑ °æ¿ì Àç½Ç½Ã
¡æ Ä¡·á½ÃÀÛÀü¿¡ catheterization or
suprapubic aspirationÀÌ¿ëÇØ 2nd culture ½Ç½Ã
#
pyelonephritis·Î »ý°¢µÇ´Â acute febrile
infection ½Ã
1) cefataxime(100mg/Kg/day)
2) ampicillin(100mg/Kg/day)
with aminoglycosides
;
gentamicin(3mg/Kg/day, 3 divided dose)
;
ototoxicity & nephrotoxicity of aminoglycosieds
-->
serum creatinine measurements(initial and daily)
; *Pseudomonas¿¡
ƯÈ÷ effective
; sodium bicarbonate¿¡ ÀÇÇÑ *urine alkalinizationÀ¸·Î
È¿°ú Áõ°¡
3) bactrim
;
Pseudomonas Á¦¿ÜÇÑ G(-)¿¡
effective
4) *ciprofloxacin
;
*18 ¼¼À̻󿡼 resistant microorganismÀÇ
alernative agent
¡Ø87 UTI Ä¡·á
ÈÄ planning
;
1ÁÖÀÏÈÄ
urine culture ÇÊ¿ä
-
urine sterility È®ÀÎ
; asymptomaticÀ̶óµµ
1¡2³â°£ 3°³¿ù °£°ÝÀ¸·Î
follow-up culture ½Ç½Ã
-
UTI´Â predisposing factor¾øÀ̵µ
recur Òý
#
anti-biotic prophylaxis
;
agent
- bactrim, nitrofurantoin
- *1/3 dose once a day
;
¡Ø89,93,95 Indication
¨ç UTIÀÇ
frequent recurrence
¨è persistent
vesicoureteral reflux
¨é persistent cystitis -
incontinence, frequency, urgency
¨ê neurogenic bladder
¨ë urinary tract stasis
& obstruction
¨ì calculi
¨í reflux
#
excellent long-term prognosis
¡Ú main consequence of
chronic renal damage by pyelonephritis
; arterial hypertension ,
renal insufficiency
8.
infrequent voiding, constipation¿¡ ´ëÇÑ education
9.
antibiotic therapy & surgical or percutaneous drainage
: renal & perirenal abscess or
obstructed urinary tractÀÇ infection°¡Áø °æ¿ì
CHAPTER 493. Vesicoureteral Reflux
1.
¿øÀÎ : ureterovesical junctionÀÇ
valvular mechanismÀÇ incompetence
2.
why reflux harmful to kidney
1)
renal pelvis¸¦ voiding ½Ã
higher vesical pressure¿¡ ³ëÃâ
cf) normal renal pelvis
pressure : 10 mmHg
2)
bacteria°¡ bladder·ÎºÎÅÍ
kidney·Î passage°¡ ¿ëÀÌ
¨ç
intrarenal refluxµµ scar¿¡ °ü¿©
: intrarenal
collecting system¿¡¼
collecting
tubule·ÎÀÇ urine reflux & bladder
dilatation
¡æ
renal scar »ý¼º¿¡ impotant role
¨è megaureter-megacystic
syndrome (fig 493-1)
¡æ dilated ureter·Î
massive reflux
¡æ
incomplete bladder emptying
¡æ
bladder·Î rapid return
¡æ
progressive bladder emptying
3.¡Ø89
reflux nephropathy
1)
children°ú young adultÀÇ
ESRFÀÇ *15¡20%
2)
childrenÀÇ hypertensionÀÇ ÁÖ¿ä¿øÀÎ
Classification
Table 493-1
#
Primary VUR
*1)
¿øÀÎ : UVJÀÇ congenital anomaly
¨ç
short intramural ureteral tunnel
-->
valvular mechanismÀÇ efficiency °¨¼Ò
¨è
urteral orifice - lateral & cephalad direction
¨é
trigone - underdeveloped
2) Fig 493-2
#
Cystic & Bladder Instability
; reflux¸¦
precipitation or perpetuation
#
Ureteral Duplication & Ureterocele
1)
ureterocele
; *upper collecting system - obstruction
; lower collecting system -
reflux or contralateral side reflux
2)
¡Ø96 Duplicated system
¨ç *reflux ; more common
in lower ureter
¨è
lower ureter
;
*enter bladder higher & more
laterally
;
less competent vlave
¨éureter°¡
divertivulumÀ¸·Î µé¾î°¡´Â °æ¿ì
;
reflux more common
#
Congenital Neurogenic Bladder
1) ¿øÀÎ : myelomeningocele,
sacral agenesis
2) reflux : Ãâ»ý½Ã ¨÷¿¡¼ ¹ß»ý ¡æ ¨ö¿¡¼
posterior valve¿¡ ¹ß»ý
¡æ °á±¹ ¨öÀ̻󿡼 ¹ß»ý
#
Intravesical Pressure°¡ Áõ°¡ÇÑ Reflux
1) bladder outlet obstruction &
vesical dysfunction ¹ß»ý
2) infection ¾øÀ̵µ
severe renal damage °¡´É
#¡Ú VUR Grade
¡ÚFig. 493-5
1)
base
¨ç severity
¨è ureteral dilatation
& calyceal
deformityÀÇ Á¤µµ
2)
ÀÇÀÇ : prognosis & therapy
Natural History
1.
reflux garde¿¡ Áõ°¡¿¡ µû¶ó renal scarring, reflux
nephropathy È®·ü Áõ°¡
2.
intrarenal reflux½Ã scarringÀÇ
risk Áõ°¡
3.
*grade I & II reflux
1) no ureteral dilatation
2) vesicoureteral regionÀÇ
anatomy °ÅÀÇ Á¤»ó
3) child°¡ ¼ºÀåÇÏ¸é¼ *80%¿¡¼
spontaneousÇÏ°Ô ¼Ò½Ç
4.
grade III & IV reflux
1) *spontaneous
resolution ; 15%
5.
familial tendency êó
¡Å 5¼¼ ÀÌÇÏÀÇ
siblingµµ °Ë»ç
Clinical Manifestation
1.
¹ß°ß
1) UTI evaluation ½Ã
2) voiding dysfunction, renal
insufficiency, hypertension or ´Ù¸¥ UTÀÇ ÀǽɵǴ pathology½Ã ½Ç½ÃÇÏ´Â
VCUG ½Ã
Differential Diagnosis
1.
history & radiograph
: primary or secondary reflux °¨º°
1) US : renal size
2) isotopic parenchymal renal scan : scarÀÇ
rule out
2.
*continued voiding dysfunction in
spite of antibacterial prophylaxis
; anticholinergics·Î Ä¡·á
or lower urinary tractÀÇ urodynamic study
3.
reflux, infection & voiding dysfunction°¡Áø ȯÀÚ
: voiding dysfunctionÀÌ
infection¿¡ ÀÇÇØ »ý±ä°ÍÀÎÁö infectionÀ»
predisposingÇÏ´Â
refluxÀÇ ¿øÀÎÀÎÁö °áÁ¤ÇϱⰡ ¾î·Æ´Ù.
Evaluation
: refluxÀÇ
diagnosis & gradingÈÄ ½Ç½Ã
1. IVP & tomography : renal size,
scar ¿©ºÎ È®ÀÎ
2. blood pressure
3. baseline creatinine clearance
4. cystoscopy
Treatment
Primary reflux & reflex ass. /c complete
duplication
1.
¢ÞGrade I & II reflux
1) spontaneous resolutionÀÌ Òý
;
infection ¹æÁö & antibiotics
prophylaxis(bactrim, nitrofurantoin
; long-term treatment
2) Ä¡·á½ÃÀ۽à *¸Å´Þ urine
culture ½Ç½Ã
; *prophylaxis°¡ effectiveÇϸé 3°³¿ù
°£°ÝÀ¸·Î culture
3) asymptomatic bacteriuria & reflux
; harmful
; *symptomÀÌ
¾ø¾îµµ urine culture Áß¿ä
4) radionulide VCUG ; *1³â ¸¶´Ù
½Ç½Ã
5) renal US ; *1³â¸¶´Ù ½Ç½Ã
¡æ renal growth Æò°¡
6) *radionuclide
study»ó spontaneous cessation
; *another study in 3¡6mo before discontinued AB therapy
-->
confirm
7) ¢¾Indication
of surgery
; failure of antibiotic
prophylaxis
8) *DMSA
renal scan ; Ä¡·áÀÇ ¸¶Áö¸·¿¡
½Ç½Ã
¡æ
residual scar°¡Áø °æ¿ì blood pressureÀÇ
long term follow up ÇÊ¿ä
2.
¡Ø89 Grade III reflux
1) *new
scar formation Àǽɽà periodic parenchymal
scan
2) *more
than 50% of children ; surgery ½Ç½Ã
3.
Grade IV & V(ass. /c significant ureteral dilatation & upper urinary
tract change)
1) *early
surgery after a brief prophylaxis & reconfirmation
;
esp. infant¿Í young child
¡ñ
5¼¼ÀÌÇÏ¿¡¼ scar ºóµµ Áõ°¡
; *warrant
-
reflux¿¡ ÀÇÇÑ prenatal hydronephrosis°¡Áø
newborn
--> 1¼¼°æ
spontaneous improvement
Secondary reflux
1.
*duplication ÀÖ´Â
°æ¿ì ; A¿Í
µ¿ÀÏ
2.
*periureteral divertivulum ÀÖ´Â
°æ¿ì ; early surgery
3.
severe cystitis ÀÖ´Â °æ¿ì ; primary causeÀÇ
remove
4.
iatrogenic ; surgery
Results Of Surgery
1. *Cohen operation ; 97%ÀÇ ¼º°ø·ü
2.
antireflux surgeryÀÇ complication
1) refluxÀÇ persistence
2) distal ureterÀÇ
obstruction
3.
surgery ÈÄ ¹Ý´ëÃø reflux´Â ´ë°³ ÀÚ¿¬ ¼Ò½Ç
´Ù¸¥ Ä¡·á ¹æ¹ý
1.
*endoscopic injection of poly
tetrafluoroethylene(polytef) under ureteral orfice
; ªÀº ±â°£
effective
2.
*subureteric injection ; collagen,
silicone particle
3.
success rate ; 65-70%
¡Ø89 Cx of VUR
; UTI
; renal scar & atrophy
; hypertension(20%)
; CRF(reflux nephropathy)
Chapter 494 Obstruction of the urinary tract
;
¿øÀÎ - congenital(children¿¡¼´Â
M/C), trauma, neoplasma, calculi, inflamatory process, surgical procedure
Etiology
Table 494-1
#
High grade ureteral obstruction of early onset in fetal life
; result in renal dysplasia
-
from multicystic kidney to cortical dysplasia
#
Chronic ureteral obstraction
; result in hypertrophy and
later dilatation of ureter and upper collecting system
Clinical manifestation
¨ç urethral obstruction in fetus
; result in patent urachus,
urethral dilatation, ureteral dilatation, VUR, urinary extravasation (urinoma,
urinary ascites)
¨è Bilateral ureteral obstruction or
urethral obstruction
; cause *oligohydroamnion and pulmonary hypoplasia
; severe obstructive uropathyÀÏ °æ¿ì ½Å»ý¾Æ¿¡¼
Áï°¢ÀûÀÎ ¹ÝÀÀÀº renal damageÁ¤µµº¸´Ù
pulmonary insufficiency¿¡ ´õ °ü°èµÈ´Ù.
¨é ±×¹Û¿¡ obstructionÀÌ
reliefµÈ ÈÄ¿¡µµ polyuria, dilute
urine, chronic acidosis(serum creatinine levelÀº Á¤»ó), hypertrophy &
dilatation in the bladder and collecting system postobstructive diuresis°¡ »ý±æ ¼ö ÀÖ´Ù.
Diagnosis
;
often silent
;
in newborn
- palpable abdominal mass due
to hydronephrotic kidney
- *patent urachus
- *ascites(due to intraperitoneal urinary extravasation)
;
prenatally diagnosed by US
- oligohydroamnios &
pulmonary hypoplasia °í·Á
;
*Infection and sepsis
- maybe first indication of
obstructive lesion of urinary tract
- renal US for all children
with acute stage of febrile UTI
;
obstructive renal insufficiency
- *failure to thrive, vomitting diarrhea, other nonspecific symptom
;
*overflow urinary incontinence, or
poor urinary stream
- *in older children
- infravesical obstruction
;
flank or abdominal pain with N/V in acute obstruction
;
silent or vague abdominal or typical flack pain with increased fluid intake in
chronic obstruction
--> *abdominal painÀÌ ÀÖ´Â all children¿¡°Ô¼
intial study·Î abdominl US
Imaging Studies
1)
US
¨ç
screening method ¨è evaluate renal size, parenchymal
thickness, ¨é determine ureteral dilatation, ¨ê
bladder evaluation ±×·¯³ª acute ¶Ç´Â
intermittent obst. ¶§´Â minimal dilatationµÇ¹Ç·Î
misleadingÇÒ ¼ö ÀÖ´Ù.
2)
DTPA
; gross estimate of different
renal fuction dilatation
; renal pelvis¿¡
isotopeÀÖÀ» ¶§
¡æ
Furosemide adm unobst ÀÖÀ» ¶§ : prompty excretes
isotope, obst ÀÖÀ» : no or slowly excrete
isotopic
renography with iodine labeled Hippuran : more accurate but exposed
kidney¿¡ radiation¡è
3)
IVP
; preliminary radiography of
the abdomen ¡æ calculi, spinal abnormalities,
abdominal
& intestinal gas patternÀ» º»´Ù.
;
postvoiding film ¡æ residual bladder urineÀ» º»´Ù.
;
obstruction side¿¡ radiopaque mediumÀÌ ³²¾ÆÀÖ´Ù.
; *intermitten obstruction
-
*painµîÀÌ
À¯¹ßµÇ´Â acute phase¿¡ IVPÇÏ´Â°Ô °¡Àå
À¯¿ëÇÏ´Ù.
Pressure Flow Studies (Whitaker test)
;
percutaneous·Î renal pelvis¿¡
needle ³ÖÀº ÈÄ radiopaque dye perfusion ÈÄ
renal pelvis¿Í bladder»çÀÌ ¾Ð·ÂÂ÷ ÃøÁ¤
- *20cm of water ÀÌ»ó pr. grad½Ã obst.
Voiding cystourethrography
¸ðµç ureteral dilatation½Ã
¨ç VUR º¸±âÀ§ÇØ ½ÃÇà
¨è urethral obst, esp. post urethral valve
¨é infravesical obstruction palpable
bladder
ureth, catheterizationÀÌ Àß µÇÁö ¾ÊÀ¸¸é ureth strictureÀǽÉ
obstructive ureth,
lesion other than valve.
Specific Type of Urinary tract Obstruction
Hydrocalycosis
¨ç infundibular obst.ÀÎÇÑ
localized calyceal dilatation
¨è ¿øÀÎ ¦®developmental
¦±2¡Æto
infl. process : exp. *Tbc
¨é cong. obst. due to stenosis or
extrinsic vas. compr.½Ã Áõ»ó : pain(obstÀÇ
surgical correction½Ã »ç¶óÁü)
¨ê Dx. : IVP
Obstruction of the UPJ
;
¡Ø93 ¡ã
obstructive lesion in children
- *¡ãoften by cong, stenosis
of UPJ
- others causes
/
ureteral kinks, fibrous band, aberrant vv.
;
¢ÀUPJ obstructionÀÇ °¡Àå
ÈçÇÑ Áõ»óµé
-
fetal hydronephrosis in maternal ultrasonography
-
palpable renal mass in newborn
-
abd, flank or back pain
-
febrile UTI
-
hematuria after minimal trauma
;
*bilateral (20%)
#
Unilateral hydronephrosis in the fetus (normal contralat. kidney, normal AF)
; not indication for prenatal
finding
; *US - Ãâ»ý 3ÀÏÀÌÈÄ
½Ç½Ã(oliguria°¡ dilatationÀ» maskingÇÒ
¼ö Àֱ⶧¹®)
-
¡ÚÁ¤»óÀÌ¶óµµ 3 or 6 mo¶§ repeat
; mild to moderate
hydronephrosis
-
observation & F/U
; marked dilatation, renal
parenchymal thin
-
isotope renogram
-
normal renal fuctionÀ̸é F/U
/
no improvement - *diuresis renogramÀ» 6-12mo
; ¢¾surgical
repair Ix
-
involved kidney function decreased
-
bilateral involvement or solitary kidney
-
diminished overall renal function
-
palpable mass
¨ì Sx°¡Áø old children
¡æ IVP, ¸¸¾à
IVP¿¡¼ Àß ¾Èº¸Àδٸé US.
¨í D/Dx
i) megacalycosis
pelvis, ureteric dilatation¾øÀÌ
congenital non-obstructive calyceal dilatation
ii) VUR with marked dilated
& kinking of the ureter
iii) midureteral, distal
ureteral obst.
#
newborn /c renal mass D/Dx UPJ obst
i) multicystic renal
dysplasia
ii) solid renal tumor
iii) renal vein thrombosis
¨î Tx. surgical pyeloplasty
¨ï Follow up ½Ã
diuresis renography
Midureteral Obstruction
¨ç Cause
¥¡) cong. ureteral stenosis or
ureteral valve in midureter
¥¢) partially obstructed retrocaval
ureter
¥£) circumcaval ureter
; Rt. anomalous development of
vena cava with persistent ventral infrarenal subcardinal veins
; IVP ß¾
Rt.ureter°¡ 3rd lumbar vert. level¿¡¼
medially deviated.
¨è ÀÌ¿ÜÀÇ¿øÀÎ ¦®
retroperitoneal tumor
¦· fibrosis by surgery. infl.
process (CGP)
¦± radiation
Ureteral ectopia
¨ç mesonephric duct migration path ñé ¾î´À°÷¿¡³ª
¹ß»ý°¡´É
¨è drain single collecting system
; commonly belongs to upper
moiety of duplicated collecting system
¨é ureteral orifice of upper
collecting syst.
; always caudal to ureteral
orifice of lower collecting system
¨ê male
i) usually *single ectopic ureter
ii) bladder neck, urethra
above external sphinncter seminal vesicle, vas deferensµîÀ¸·Î À¯ÀÔ
iii) high grade obstruction,
UTI or epididymitis Sx.
iv) ¹Ý´ëÃøÀÌ
normal½Ã nephroureterectomy
v) bilateral single ectopic
ureter unilateral case with functioning involved kid. reimplantation
¨ë female
i) *ass. /c duplication
ii) ureter of upper
collecting system
-->
bladder neck, urethra at or above the level of sphincter
;
upper pole nephroureterectomy
iii) ureter --> vestibule,
vagina, uterus
;
urinary incontinence, vaginal discharge
iv) Dx
;
IVP, US, endoscopy with high degree of suspicion
v) bilateral simple ectopic
ureter
;
*bladder hypoplasia µ¿¹Ý
Ureterocele
;
congenital cystic dilatation of the distal ureter ¡æ
bladder³»·Î protrusionµÇ¾î
pin point
;
¿© ¡µ³²
;
simple ureterocele
¥¡)
non-duplicated collecting system orifice´Â Á¦À§Ä¡(bladder³»¿¡ êó)
¥¢)
IVP ß¾
;
varying degree of ureteral & calyceal dilatation, round filling defect in
bladder delayed film¿¡ ureter°¡
cleanred visibleÇϰųª & filling of contrast mediaÀÏ ¼öµµ ÀÖ´Ù.
¥£)
Tx.
transurethral incision of
uretercele (¶§·Î VUR ÃÊ·¡ÇÏ¿©
ureteral reimplant ÈÄ¿¡ ʦ)
open excision of ureterocele
& reimplartation
upper tract dilatation ¾ø´Â
small ureterocele½Ã No Tx.¡æ
pr. flow study & diuresis
;
ureteral duplication µ¿¹Ý
- ÁÖ·Î *upper renal moiety¿¡¼ drainÇÏ´Â ureter°¡ ectopic ureterocele Òý
- upper renal moiety : poor
fuction, cong.obst.À¸·Î dysplastic
- lower renal moiety :
frequently reflux
- ectopic ureterocle may extend
submucosally into post. urethra
/
´ëºÎºÐ unilateral
;
UTI
;
bladder neck obst.
;
urinary retention, reflux µîÀÇ ¾ç»óÀ» º¸ÀÓ
;
IVP
¨Í
large filling defect in bladder
¨Î
characteristic finding of duplication
¦®
upper collectin syst. - poor or absent function.
¦±
lower collecting syst. - caudal displacement
¡æ
"drooping lily app"
;
Tx
¨Í
excision of upper collecting system : partial nephrectomy & ureterectomy
¨Î
small ectopic ureterocele with ipsilateral duplicated ureter¿¡
low or no reflux½Ã : No Tx.
¨Ï
large ureterocele with ipsilateral lower ureter¿¡ high grade reflux½Ã
: excision of ureterocele & reimplantation of remaining ureter £«
partial upper moiet
¨Ð
obstructing, ureteroceleÀ» °¡Áø acutely ill, septic
infant½Ã involved collecting systemÀÇ
drainage by transureterally or by percut. nephrostomy°¡ ÇÊ¿äÇÔ
Megaureter
¨ç dilated ureter
¨è careful Hx. PE. voiding
cystourography µîÀÌ 2¡Æmegaureter¿ÍÀÇ
DDxÀ§ÇØ Áß¿ä
¨é º¸Åë distal ureter°¡
more dilatedµÇ¾î ÀÖ°í bladder¿ÍÀÇ
junction¿¡¼ °©ÀÚ±â
tapperingµÈ´Ù.
¨ê
obst. megaureter¿Í nonobst. megaureter DDxÀ§ÇØ
dieuresis renogram press
flow study µî ÇØ¼ obstÀ̸é
opÇØÁØ´Ù.
Table 494-2
¡Ø91½½
Prune-Belly Syndrome
(=abdominal
muscle deffciency syndrome =Eagle -Barrett syndrome)
;
1/40,000
;
*97% male
¢Þ Characteristics
-
deficient abdominal muscle
-
undescended testes
-
urinary tr. abnormality result from urethral obstruction in fetal life
/
ureter & upper partÀÇ mass dilatation, large bladder
with patent urachus, VUR, urachal diverticulum, dilated prostatic urethra,
hypoplastic prostate, dysplastic kidney, megalourethra
;
*oligohydramnios, pul. hypoplasia -
frequent Cx
;
bowel malrotation c universal mesentery
;
cardiac anomaly (10%)
;
musculoskeletal anomaly (more than 50%)
;
1/4 - at birth urethral obst.(£«)
;
Ä¡·á
- obstructionÀÌ ¾øÀ¸¸é
UTI¿¹¹æÀÌ Ä¡·áÀÇ ¸ñÇ¥´Ù.
-
obst.. (£«) / temporary drainage & later
reconstructive surgery
- orchiopexy : 1¼¼À̳»
;
¿¹ÈÄ
- ¡Úpulmonary
& renal dysplasiaÁ¤µµ¿¡ ´Þ·ÈÀ½.
- 1/3Àº »ç»êµÇ°Å³ª
Ãâ»ýÈÄ ¼ö°³¿ù ³»¿¡ pulmonary CxÀ¸·Î Á×À½
- Àå±â »ýÁ¸ÀÚÀÇ °æ¿ì
1/2°¡ CRF·Î °¡¸ç ÀÌ °æ¿ì KTPÈÄÀÇ °æ°ú´Â ¾çÈ£ÇÏ´Ù.
Bladder Neck Obstruction
¨ç ¿øÀÎ
2¡Æto ectopic ureterocele.
bladder calculi, prostatic
tumor(rhabdomyosarcoma)
post. ureth. valve ; functional
disturbance´Â rare neurogenic bladder
dysfuction
¨è Sx. : difficulty voiding, urinary
retention, UTI bladder distention with overflow incontinence
¨é 1¡Æbladder neck obst is
exceptional in males
¡Ø94 Posterior Urethral Valves
;
urethral valve ñé *¡ãcommon type
;
sail-shaped membrances with eccentric opening
- *verumontanum¿¡¼ ½ÃÀÛÇÏ¿©
distally extend
-->
attach to anterolateral wall of urethra
;
dilated prostatic urethra, detrusor m. & bladder neck hypertrophy
--> VUR
;
oligohydroamnios, pul. hypoplasia
#
prenatally diagnosed case
; severe obstruction
-->
prenatal bladder decompression by percutaneous vesicoamniotic shunt or open
fetal surgery
; *worse prognosis than detected after birth
#
severe case
; *failure to thrive due to uremia
; *sepsis due to UTI
#
lesser severe case
; *difficulty in maintaining urinary continence
Diagnosis
; VCUG
-
prostatic urethral dilatation with transverse linear filling defect
-
VUR : 2/3
Treatment
#
serum Cr - normal or return to normal
; primary ablation of valve
through transurethral approach
;
by temporary vesicostomy if insufficient urethral caliber
#
serum Cr - high or ¡è despite bladder drainage
; suspect 2ndary ureteral
obstruction, irreversible renal damage, renal dysplasia
; upper tract drainage
-
cutaneous pyelostomy, high ureterostomy
#
no improvement of renal function
; reconstructive surgery at
early age
#
septic & uremic Pt
; electrolite imbalance
; Abt ÈÄ ¨Í
percut. nephrostomy
¨Î renal analysis stableÇÑ ÈÄ
evalutation & Tx
#
incontinence°¡ ÁÖ¼ÒÀÎ °æ¿ì
; primary valve ablation
#
*VUR
; expectant Tx. with AB
therapy
-->
*relux°¡ 1 yr ¡è & kidney function ¡é
-->
surgical correction
#
*Tx.ÈÄ¿¡µµ urinary incontinence 50%
¥¡)
surgical damage of sphincter
¥¢)
dilatation of prostatic urethra
¥£)
poor bladder compliance
¥¤)
polyuria from renal damage
--> *³ªÀ̵é¸é (exp. after puberty)È£Àü
;
*Px in newborn
- depend on pul.hypoplasia
& renal function recovery potential
- neonateÀÌÈÄ¿¡
1/3¿¡¼ ¾î´À Á¤µµÀÇ Renal insuff.ÀÖ¾î
renal transplantation ¿äÇÔ
Urethral Stricture
¨ç male
¥¡)
congenital : rare
¥¢) urethral trauma
;
iatrogenic (cath, endoscopic, ureth, reconstr.)
;
accidental (straddling injury, pelvic fracture)
¥£)
Sx.
;
¨Í bladder instability ¨Î
hematuria ¨Ï dysuria
¥¤)
Dx
;
voiding film of IVP RGCU, endoscope
¥¥)
Tx
;
short - endoscopic dilatation & internal urethrostomy
;
long - urethroplasty
¨è female
; true is exceptional
; urethral ring ¡æ
urethral obst. & UTI ÃÊ·¡
Anterior Urethral Valve & Urethral Diverticula In
Male
¨ç µÎ °³ µ¿¹Ý ʦ
¨è Dx : VCUG
¨é diverticula´Â
dilatation of Cowper gland & duct·Î »ý°¢
Male Urethral Meatal Stenosis
;
4¼¼ ÀÌÇÏ - 8F ¡é,
10¼¼ÀÌ»ó - 10F ¡é
¡æ
true meatal stenosis
;
neonatal circumcision ÈÄ glansÀÇ
ammoniacal dermatitis ÀÎÇØ ¹ß»ý
;
hypospadia ½Ãµµ ʦ
;
Tx. : meatoplasty
Chapter. 495. Anomalies of the Bladder
Bladder Extrophy
;
ºóµµ
-
1/40,000 birth.
-
boys ¡µgirls
Clinical Manifestations
¨ç mesodermÀÌ
cloacal membraneÀ¸·Î caphaled extension ¾ÈµÇ¾î õó
¨è classic °æ¿ì
bladder
protrusion from the abd. wall
exposure
of bladder mucosa
downward
displacement of umbilicus
wide
separated public rami
separated
recti m.
ant.
displaced anus with rectal prolapse
:
complete epispadia with wide & shallow scrotum undescended testes inguinal
hernia
female : epispadia, clitoral duplication wide separation of labia
broad based gait : wide separated public rami¶§¹®
¨é untreated °æ¿ì
¥¡) total urinary incontinence
¥¢) bladder Cancer ¡è,
esp. adenoCa.
Treatment
;
Ãâ»ý Á÷ÈÄ bladder¸¦
silastic shield³ª ´Ù¸¥ Àû´çÇÑ plastic dressingÀ» ÇØ¼
desication of bladder¸¦ ¸·´Â´Ù.
;
*48hrÀ̳» closure of the exstrophied bladder
- before permanant changes in
the bladder walls
- flexibility of pelvic joint
ÀÖÀ»¶§ ½ÃÇà
;
initial op. ¸ñÀû
¥¡)
precise closure of the bladder & prostatic urethra in male
¥¢)
elongation of the urethral plate & penis
¥£)
closure of the abd. wall
;
´ëºÎºÐ ÈÄ¿¡ VURµ¿¹Ý
;
epispadia operation
- 1-2yr
;
Tx of incontinence by bladder neck reconstruction
- *after rectal control
Prognosis
¨ç Ä¡·áÈÄ¿¡ upper urinary tract¿¡¼
15%ÀÌÇÏÀÇ deterioration. 70% ÀÌ»óÀÇ
continence¸¦ ȹµæÇÑ´Ù.
¨è À̹ۿ¡ artificial sphincter¸¦ ¸¸µé°Å³ª
cytoplasty, abdominal stoma, ureterosigmy µîÀ» Çʿ信 µû¶ó ÇØÁֱ⵵ Çϳª ÀÌ·± op´Â
ch. pyelonephritis, urinary tract damage ÀüÇØÁú ºÒ±ÕÇü, Àå±â°£ °æ°ú ÈÄ
carcinoma ÀÌÇà µîÀÇ À§Çè·üÀÌ ÀÖ´Ù.
Other Exstrophy Anomalies
¨ç cloacal exstrophy
severe abn. of colon, rectrum, short
bowel
¨è epispadia
distal epispadia : reconstruction
of urethra & penis
Bladder Diverticula
;
*´ë°³ UVJ¿¡
È£¹ß ¡æ VUR
¨ç ¿øÀÎ
¦® congenital
¦± commonly asoc. distal ureth. obst.
neurogenic bladder dysf.
¨è Tx.
; small : none
; large ¡æ
ineff. voiding, residual urine stasis. UTI½Ã excision
[urachal anomaly] : male ¡µfe
Chaper 496. Neurogenic Bladder
Etiology
;
congenital
;
meningomyelocele, lipomeningocele, sacral agenesis, other spinal abnormalities
;
acquired & traumatic
- less frequent
- cerebral palsy, CNS tumor
& their treatment pelvic op. (imperforated anus, sacrococygeal, teratoma)
;
¡Útwo ¡ãimportant consequences
- *upper tract deterecration, urinary incontinence
Renal Damage
;
dys-synergia
--> functional obstruction
of bladder outlet
--> high intravesical
pressures
--> bladder muscles
hypertrophy, trabeculation
--> VUR
--> deterioration of upper
tracts
;
VUR
- 30% of neonate with
myelomeningoceles, later 20%
- *more severe than primary reflux
;
infection
- compounds problems
;
neurologic anomaly °¡Áø PtÀÇ ¸ðµÎ°¡ neurogenic bladder ÀÖ´Â °ÍÀº ¾Æ´Ï¹Ç·Î
urodynamic study(cytometrography sphincter electromyography)ÇÏ¿©
R/O½ÃÄÑ¾ß ÇÔ.
Urinary incontinence
;
¿øÀÎ
¨Í
total or partial denervation of sph.
¨Î
bladder hyperreflexia or poor bladder compliance
¨Ï
chronic urinary retention
3)
Tx
¨ç Neurogenic bladder °¡Áø ȯÀÚ Ä¡·áÀÇ ¸ñÀû
protection of upper urinary tract
eventually providing continence
¨è newborn with low intravesical pr.
& No VUR
expectant therapy
US & radioisotopic cystogram f-up
recurrent UTI½Ã prolonged antibiotic therapy
urodynamic study at 6 mo.¿¡ repeat
¨é VUR(+), elevated intravesical pr.
(grade ¥°&¥±)
¦® Antibiotics prophylaxis
intermittent catheterization
¦² anticholinergic drug(oxybutynin
0.4mg/kg/day Sig 1/2)p.o½Ã 40%¿¡¼ È£Àü
¦± severe reflux ÀÖÀ» °æ¿ì
corrective surgery
incontinence Tx
¥¡)
sphincter tone ÃæºÐÇÏ´Ù¸é ¡æ 4hr °£°ÝÀ¸·Î
intermittent catheterization
¥¢)
7¡8 yr. old who have adequate manual
dexterity ¡æ intermittent self
catheterization
¥£)
intermittent catheterization µ¿¾È antibacterial prophylaxis ¾µ ¼ö ÀÖ´Ù.
¨ë
bladder capacity¿Í compliance´Â ÃæºÐ.
but urethral resistance°¡ ³·À» ¶§
implanatation of artificial sphincter
¨ì
Enterocytoplasty
¥¡)
Tx : neurogenic bladder bladder exstrophy, post urethral valve µî
bladder
capacity¸¦ ÁÙÀÌ´Â Áúȯ
¥¢)
Rt. or Lt. colon À̳ª ileumÀ» ³¢¾î ³ÖÀ½
¥£)
ÀÌ °æ¿ì intermittent cathÇÒ ¶§ colonÀÇ G(-) bacteria ³ª¿À¹Ç·Î
Sx ÀÖÀ» ¶§¸¸
UTI Tx
¥¤)
hypermetabolic acidosis ¿Ã ¼ö ÀÖÀ¸¹Ç·Î Tx (enteric mucosal
surface ñé urine°ú Á¢ÃËÇÏ´Â ºÎºÐ¿¡¼
ammonium, choloride. H+À̿ Èí¼ö, K+ lossÇϹǷÎ)
¥¥)
ÀÌ·± Cx ¸·±â À§ÇØ ch. renal
insufficiency ȯÀÚ¿¡°Ô´Â colon ´ë½Å
gastric segment¸¦ »ç¿ëÇϱ⵵ ÇÔ.
¥¦)
CxÀ¸·Î perforation, peritonitis,
potential for malignancy µîÀÌ ÀÖÀ½.
Chaper 497. Voiding dysfunction
Nocturnal Enuresis
¨ç 5¼¼ childÀÇ
20%
; ±× ÀÌÈÄ ÇØ¸¶´Ù
15% °¨¼ÒÇÏ¿© adult¿¡¼´Â
1%ÀÌÇÏ
¨è ¿øÀÎ
; *delayed maturation of the cortical mechanism
; alteration of the circadian
rhythm of ADH secretion
¨é primary
; night-time continence period (-)
secondary
; formely dry child¿¡¼ emotionally disruptive event ÈÄ¿¡ ¹ß»ý
¨ê male(3¹è)
¡µfemale
¨ë FHxÀÖ´Ù.
¨ì neurologic & spinal
abnormality, fluid intack, urinary output
¨í urinalysis
; Bacteriuria
; specific gravity &
osmolarity after overnight fast
¨î daytime sx. (-). P/E, UA, urine
culture normal½Ã ¡æ No further evaluation
needed
¨ï Tx
¥¡)
reassurance. self - limited, eliminate punitive measure
¥¢)
fluid restriction, midnight awakening systems of reward & punishment :
not successful
¥£)
imipramine drug ²÷À¸¸é ´ë°³ recur
¥¤)
desamino - D - arginine vasopressin : 50%
¥¥)
Tx. of conditioning with alarm.
Unstable Bladder
¨ç voiding dysfunction not related
to neurologic abNl or dys Fx
¨è Sx : frequency, urgency, blader
pain¾øÀÌ diurnal urinary incontine
¨é Study
Hx P/E UA, urine culture,
uroflowmeter, abdo U/S, male - VCUG
¨ê Fx
UT pathology¾øÀ» ¶§
oxybutynic & other anticholinergic
Non-Neurogenic Neurogenic Bladder
¨ç non neurogenic
destrusor/sphincter dys°ú °°Àº ¸»
¨è neurologic abnormal ¾øÀÌ
voiding ½Ã ext sphincter°¡
relax(-)
¨é Hx»ó UTI Constipation Hx ÀÖ´Ù.
¨ê P/E»ó
VUR
trabeculated bladder, decreased urine flow rate intermittent pain
¨ë toilet training°ú °ü·Ã
¨ì Tx
¥¡) treatment of reflux &
antibiotics prophylaxis
¥¢) behavioral modefication &
encouragement of relaxation during voiding
¥£) Buifeedback
¥¤) intermittent catheterization
& anticholinergic drug
¥¥) diazerpam
¨í Px : poor
Infrequent Voiding
¨ç UTI¿Í µ¿¹ÝµÈ micturition ¶§
common disorder
¨è girls¿¡ Òý,
FHx°¡ ÀÖ´Ù.
¨é ¿øÀÎÀº behavioral
¨ê Tx : antiotics prophylaxis.
encourage to frequently void
complete emptying by double voiding
Other Cause Of Incontinence In Females
table
497-1
1)
Ureteral ectopia
¨ç ´ë°³ female¿¡¼
duplicated collection system°ú µ¿¹Ý
¨è Nl voiding pattern º¸À̸é¼
constant dribbing of urine
¨é Dx : IVP, US, CT of kid, Exam
under anesthesia for ectopic ureteral orifice in vestibula or vagina
¨ê Tx : partial nephroureterectomy
Chapter 498. Anomalies of the penis and urethra
Hypospadiasis
¨ç ºóµµ : 1/500 newborns.
¨è
mildestÇÑ °æ¿ì uretheral meatus°¡
glansÀÇ vent·Î
openÇÏ´Â °Í¿¡¼ºÎÅÍ severeÇÒ ¼ö·Ï
penis°¡ ventral·Î
curvedµÇ¸é¼ penile urethra°¡ ª¾ÆÁø´Ù.
(chordeeµ¿¹ÝµÇ¾î¼)
¨é meatusÀÇ
opening : ventral aspect of glans, penoscrotal juction, perineum
¨ê 10%¿¡¼ undescended testes µ¿¹Ý
¨ë Ä¡·áÀÇ ¸ñÀû mild case : cosmatic
severe case : ¼¼ voidingÇÒ ¼ö ÀÖ°Ô
future Nl sexual function
avoid psychogenic consequence
¨ì
ideal age for repair´Â controversialÇÏÁö¸¸ ÇöÀç
18mo.ÀÌÀü¿¡ ½ÃÇà ¡æ toilet
training(1¼¼Àü)¿¡ ½Ç½Ã newborn period¿¡ ½ÃÀÛ
(routine circum ÇÇÇÒ °Í)
Agenesis and Micropenis
A.
agenesis : rareÇÏ¿© anorectal and rectal anomalies¿Í µ¿¹Ý ¸¹ÀÌ ÇÔ.
B.
Micropenis
normal NB penic : 3.5¡¾0.7cm
primary
secondary testicular failure after complete morphogenesis
anencephaly
pituitary agenesis
Kallmann, Noonan, Prader - Willi
synd
rudimentary testes
dwarfism
materna hormone administration
Tx. : ¨ç
hormone stimulation
¨è
rearing as female with later genital reconstruction
Phimosis & Paraphimosis
phimosis : prepuce°¡
retractionµÉ ³ªÀÌ(3¼¼)°¡ Áö³ªµµ
retractionµÇÁö ¾Ê´Â °ÍÀ¸·Î inflamationÀÇ
sequal·Î µÇ´Â °Í°ú congenital·Î µÇ´Â °ÍÀÌ ÀÖ´Ù.
Paraphimosis : phimotic preuce°¡
coronal sulcus µÚ·Î retractµÇ¾î
reduceµÉ ¼ö ¾øÀ» ¶§, ÀÌ ¶§
edema severe pain È£¼ÒÇϸç Ãʱ⠹߰ßÇϸé heavy sedationÀ̳ª Àü½Å¸¶Ãë ½ÃŲ ÈÄ
lubricationÇØ¼ foreskinÀ»
reduce½ÃŲ´Ù.
Chapter 499. Disorders and Anomalies of the Scrotal Contents
Undescended Testes
Andescended & Ectopic testes
1)
Cryptorchidism
¨ç true undescended testes : normal
path of descent µû¶ó Á¸Àç
processus vaginalis : patent
ectopec testes : inguinal canal ÅëÇØ complete descent ÇßÀ¸³ª
subcut location¿¡
end up
M/C : lat to the ext.
inguinal ring below subcut. fascia
#
incidence
; 0.7% of children after 1yr
and adults
; 3.4% in newborn
; prematurity(2000¡2500g)
- 17%
; 900gm¡é
- 100%
#
7th mo. of gestation½Ã testicular descent õó
#
*spontaneous testicular descent dose
not occur after 1yr
#
Complication
¥¡) infertility in adulthood
¥¢) tumor development : 20¡44%
¡è risk
¥£) associated hernia
¥¤) torsion of the cryptorchid
testis
¥¥) psychologic effects of an empty
scrotum
#
bilateral cryptorchidism : 30%
¨ë
undescended testis´Â ¿ø·¡ Á¶Á÷ÇÐÀûÀ¸·Î´Â Á¤»óÀ̳ª failure of
developement and
atrophy°¡ ÀϾ 3rd or 4th decade of
life¿¡¼´Â maligrant testcular°¡ µÉ È®·üÀÌ 20¡44%
Áõ°¡µÈ´Ù. ÀÌ Áß¿¡¼ M/C tumor´Â
Seminoma(60%)ÀÌ´Ù. (Á¤»ó testes¿¡ ¼´Â
30%)
¨ì
true undescended testes¿¡¼ indirect inguinal hernia°¡ ¹Ýµå½Ã ³ªÅ¸³ª¸ç À̹ۿ¡
torsion infarctionÀÌ µ¿¹ÝµÉ ¼ö ÀÖ´Ù.
Treatment
#
unilataterl cryptorchid testes
; *orchiopexy during early in the 2nd yr. of life
#
bilateral
; palpable testis
-
unilateral °ú µ¿ÀÏÇÏ°Ô Ä¡·á
; not palpable testes
-
*hCG stimulation test
/
testosterone¡è½Ã abd. exploration & orchoipexy
/
negative responseÀÏ ¼öµµ ÀÖ´Ù
¥£)
HCG or LHRH
surgical
Tx. replacement ¸øÇÔ
1,000u im.3
times weekly for 3 wk ÈÄ testesÇϰ
(-), orchiopexy
Retractile Testes
exaggerated cremasteric reflex·Î
inguinal canal³»·Î retract
puberty ¶§
scrotumÀ¸·Î ³»·Á¿È
No Cx
Abscent testes
non-palpable testesÀÇ
200%
¦®congenital : quite rare
¦±acquired : vascular accident
Torsion Of The Testis Or Appendices
¨ç 6»ì ÀÌÇÏ¿¡¼ acute scrotal pain
swellingÀ» È£¼ÒÇϴ ȯ¾ÆÀÇ 40%¿¡¼
testicular
torsion ÀÌ´Ù.
¨è ¿øÀÎ ¡æ abnl. fixation of the
testis to the scrotal envelope
¨é Sx ¡æ acute scrotal pain,
tenderness, swelling absent cremasteric reflex
¨ê DDx
¥¡) incarcerated hernia ¡æ ÀÌ ¶§´Â
inguinal area¿¡ swelling ÀÖ´Ù.
¥¢)
torsion of one of the 0testicular or epididymal appendicies ¡æ ÀÌ ¶§´Â
pain
swelling Àû°í testisÀ§¿¡
blue dot º¸À̰í local tenderness
¥£) epididymitis : 13ÀÌÈÄ¿¡´Â ¹Ýµå½Ã
R/O
18¼¼ ÀÌ»ó½Ã M/C cause of scrotal
pain & swelling
ÀÌ ¶§ UA°¡
abnormal
¨ë Áø´Ü¹ý : ultrasonogram, color
doppler, ultrasound, isotope scan
¨ì Tx
prompt surgical exploration 6hÀü¿¡
retorsion½Ã 90%¡è¿¡¼ survival of gonad
contrlateral testes´Â scrotum¿¡
fixation
Varicocele
;
pampaiform venous dilatation due to valvular incompetence of spermatic vein
;
*predominantly Lt side
- bilateral 10%
;
rare before 10yr, adult 15%
¨é subfertility, decreased size of
testis ʦ
¨ê large½Ã
painful, fixed varicocele : retreoperitoneal tumorÀǽÉ
¨ë surgery : pain relieve, normal
testis development ¸ñÀû
¨ì varicocelÀÇ
early correction°ú fetility¿¡ ´ëÇÑ °ü°è´Â ¾ÆÁ÷ ¹àÇôÁöÁö ¾Ê¾ÒÀ½.
Hydrocele
¨ç tunica vaginalis¿¡
fluid accumulation transillumination (+)
¨è small hydroceleÀº
1yr³» ¼Ò½Ç
¨é communicating hydrocele (vary in
amount)½Ã´Â indirect inguinal herniaó·³
Tx.
Epididymitis
acute scrotal pain & swelling
cong. anomaly of wolffian duct
(ectopic ureter entering the vas.)
UA : pyurea gonococcus Chlamydia
Tx. : bed rest antibiotics
Chapter 500. Trauma to the Genitourinary Tract
¨ç Trauma·Î ÀÎÇÑ
accidental injuryÀÏ °æ¿ì skeletalÀ̳ª
CNS µî ´Ù¸¥ °÷Àº trauma¿Í µ¿¹ÝµÉ °æ¿ì°¡ ¸¹°í ¸¸¾à
kid¸¸ Trauma ¹Þ¾Ò´Ù¸é ¼±ÇàÇÏ´Â
kid anomaly°¡ ÀÖÀ» È®·ü ÀÌ ¸¹´Ù.
(horseshoe kid, renal ectopia, hydronephrosis)
¨è Evaluation of Pt.
¥¡) bladder cath. : except bleeding
from urethra
urethral injury½Ã retrograde urogram
Tx.
: suprapublic cystostomy drainage until resorption of hematoma ¡æ
urethroplasty
Cx. : erectile impotence urethral stricture urinary incontinence
¥¢) cystography
¥£) IVP
¥¤) renal angiogram, CT
¨é Renal injury ºÐ·ù
minor
- parenchymal ¼Õ»ó, ´ëºÎºÐ ÀÌ°Í op. ÇÊ¿ä¾ø´Ù.
major
- collecting system, renal pedicle ¼Õ»ó
¨ê infant & child¿¡¼
Kidney¿¡ injury È£¹ßÀÌÀ¯
proportionally greater size
less sturdy fatty & fascial
envelope
greater flexibility of overlying
lower ribs
Chapter 501. Urinary Lithiasis
¨ç ±âÈÄ, À½½Ä, »çȸ °æÁ¦Àû ¿ä¼Ò¿Í ¿¬°üµÇ¹Ç·Î
geographic variationÀÌ ÀÖ´Ù.
¨è Sx. ¼ø¼
¥¡) gross or microscopic hematuria
¥¢) abd. pain
¥£) flank or back pain
¥¤) UTI sx
¨é plain abd. ß¾
¥¡) faintly seen ¨Í
cystine stone ¨Î infectious stone(Struvite)
¥¢) radiolucent stone
¨Í uric acid ¨Î
2.8-dihydroxyadenine ¨Ï xanthine calculi ¡æ
US, IVP, CT·Î Áø´Ü.
¥£) complete functional &
radiographic study 1/4¿¡¼ VUR(+)
¥¤) chemical & crystallographic
analysis
¨ê laboratory tests suggested to
evaluate urolithiasis
table 501-1
¨ë classification of urolithiasis
table 501-2
Calcium Stones
;
calcium oxalate
- *¡ãcommon urinary caculi
¨ç ¿øÀÎ
¥¡) idiopathic urolithiasis
¥¢) associated with hyperclacemia
¨Í hyperparathyroidism
¨Î sarcoidosis
¨Ï immobilization
¨Ð hypervitaminosis D
¨Ñ idiopathic, isolated form
¥£) normocalcemic hypercalciuria
furosemide adm.
uncontrolled distal RTA
TPN, alkalosis
idiopathic
renal tubular calcium leak¡æ 2ndary
hyperparathyroidism.
¡æ hyperabsorption of calcium
(primary intestinal hyperabsorption of calcium)
¨è urinary calcium measurement
upper limit of normal : 4mg/kg/24h
urinary Ca/creatinine ration ¡µ0.25mg/mg
¨é calcium oxalate stone
small bowel ds. & malabsorption
¡æ intestinal hyperoxaluria 1¡Æhyperoxaluria
(type 1 or 2)
Cystinuria
dibasic
amino acids(cystine, ornithine arginine, lysine,)ÀÇ transportÀÇ
inborn error½Ã
¡æ excessive urinary excretion of
products
¡æ formation of calculi
Struvite Stones
urea
splitting organism
(¨ç
Proteus, occasionally ¨è Klebsiella ¨é
E. coli ¨ê Pseudomonas) ¡æ
urine alkalinazation, excessive ¡æ
magnesium ammonium phosphate (struvite), calcium phosphate
aluminum
phosphate Ä§Âø
Uric Acid Stones
¨ç ´ë°³ hyperuricosuria with or without
hyperuricemia
radioluscent stone
persistent acid urine & urate crystalluri½Ã ÀǽÉ
¨è ¿øÀÎ
inborn error of purine metabolism
¦£
Lesch - Nyhan. syndrome
¦¢
G-6PD-deficiency
¦¢
short-bowel synd. (esp. ileostomy)
¦¢
chronic dehydration & acidosis
¦¦
tumor & myeloprolif. ds.
cf.
2.8. dihydroxyadenine lithiasis
adenine phosphoribosyltransferase def.
Treatment
#
2 prospectives
; underlying metabolic
disorder Tx.
-
infection, predisposing anatomic factor
; Tx of complication
associated with stone itselfs
-
infection & obstruction
recurrence
¹æÁö
¨ç adequate state of hydration &
diuresis
¨è alteration of pH
¥¡)
cystine, uric acid pH 7.5ÀÌ»óÀ¸·Î alkalinazation½Ã
solubility ¡è
¥¢)
struvite½Ã acidic urine
¨é therapy for underlying
0metalbolic disorder
¥¡)
thiazide : primary renal hypercalciurla
¥¢)
RTA Tx.
¥£)
allopurinol(uric acid stone. 2.8 - dihydroxvadenosine)
¥¤)
D-penicallamine (cystine, hemicystine)
¥¥)
N-acetyl cystine - cystine stone
¨ê ¥¡) cellulose phosphate ¡æ
primary absorptive hypercalciuria
¥¢) pyridoxine ¡æ
hyperoxaluria
¥£) salts of phosphate, citrate,
magnessium ¡æ calcium oxalate solubility Áõ°¡
#
surgical Tx
; *ÃÖ±Ù¿¡´Â °ÅÀÇ
ÇÏÁö ¾ÊÀ½
; obstruction of collecting
system, pain, bleeding, perpetuating infectionÀÌ ÀÖÀ»¶§ ½Ç½Ã
#
endoscopical or percutaneous access to kid
#
extracorporeal shock wave lithotripsy
; *renal & ureteral stone ¸ðµÎ °¡´É
; *succes rate - more than 75%