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EAU Guidelines on Paediatric Urology 2016

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EAU Guidelines on Paediatric Urology S. Tekgül (Chair), H.S. Dogan, P. Hoebeke, R. Kocvara, J.M. Nijman (Vice-chair), C. Radmayr, R. Stein Guidelines Associates: E. Erdem, A.K. Nambiar, M.S. Silay, S. Undre European Society for Paediatric Urology © European Association of Urology 2016 TABLE OF CONTENTS PAGE 1. INTRODUCTION 8 1.1 Aim 8 1.2 Panel composition 8 1.3 Available publications 8 1.4 Publication history 8 1.5 Summary of changes 8 1.5.1 New and changed recommendations 9 1.5.2 Summary of evidence 10 2. METHODS 10 2.1 Peer review 10 2.2 Future goals 10 3. THE GUIDELINE 11 3.1 Phimosis 11 3.1.1 Epidemiology, aetiology and pathophysiology 11 3.1.2 Classification systems 11 3.1.3 Diagnostic evaluation 11 3.1.4 Management 11 3.1.5 Follow-up 12 3.1.6 Summary of evidence and recommendations on the management of phimosis 12 3.2 Management of undescended testes 12 3.2.1 Background 12 3.2.2 Classification 12 3.2.2.1 Palpable testes 13 3.2.2.2 Non-palpable testes 13 3.2.3 Diagnostic evaluation 14 3.2.3.1 History 14 3.2.3.2 Physical examination 14 3.2.3.3 Imaging studies 14 3.2.4 Management 14 3.2.4.1 Medical therapy 14 3.2.4.1.1 Medical therapy for testicular descent 14 3.2.4.1.2 Medical therapy for fertility potential 15 3.2.4.2 Surgical therapy 15 3.2.4.2.1 Palpable testes 15 3.2.4.2.1.1 Inguinal orchidopexy 15 3.2.4.2.1.2 Scrotal orchidopexy 16 3.2.4.2.2 Non-palpable testes 16 3.2.4.2.3 Complications of surgical therapy 16 3.2.4.2.4 Surgical therapy for undescended testes after puberty 16 3.2.5 Undescended testes and fertility 17 3.2.6 Undescended testes and malignancy 17 3.2.7 Summary of evidence and recommendations for the management of undescended testes 18 3.3 Hydrocele 18 3.3.1 Epidemiology, aetiology and pathophysiology 18 3.3.2 Diagnostic evaluation 18 3.3.3 Management 19 3.3.4 Summary of evidence and recommendations for the management of hydrocele 19 3.4 Acute scrotum 19 3.4.1 Epidemiology, aetiology and pathophysiology 19 3.4.2 Diagnostic evaluation 20 3.4.3 Management 20 3.4.3.1 Epididymitis 20 3.4.3.2 Testicular torsion 20 3.4.3.3 Surgical treatment 21 3.4.4 Follow-up 21 2 PAEDIATRIC UROLOGY - UPDATE MARCH 2016 3.4.4.1 Fertility 21 3.4.4.2 Subfertility 21 3.4.4.3 Androgen levels 21 3.4.4.4 Testicular cancer 21 3.4.5 Summary of evidence and recommendations for the management of acute scrotum in children 21 3.5 Hypospadias 22 3.5.1 Epidemiology, aetiology and pathophysiology 22 3.5.1.1 Risk factors 22 3.5.2 Classification systems 22 3.5.3 Diagnostic evaluation 22 3.5.4 Management 23 3.5.4.1 Age at surgery 23 3.5.4.2 Penile curvature 23 3.5.4.3 Preservation of the well-vascularised urethral plate 23 3.5.4.4 Re-do hypospadias repairs 24 3.5.4.5 Urethral reconstruction 24 3.5.4.6 Urine drainage and wound dressing 24 3.5.4.7 Outcome 25 3.5.5 Follow-up 25 3.5.6 Summary of evidence and recommendations for the management of hypospadias 25 3.6 Congenital penile curvature 25 3.6.1 Epidemiology, aetiology and pathophysiology 25 3.6.2 Diagnostic evaluation 26 3.6.3 Management 26 3.6.4 Summary of evidence and recommendations for the management of congenital penile curvature 26 3.7 Varicocele in children and adolescents 26 3.7.1 Epidemiology, aetiology and pathophysiology 26 3.7.2 Classification systems 26 3.7.3 Diagnostic evaluation 27 3.7.4 Management 27 3.7.5 Summary of evidence and recommendations for the management of varicocele 28 3.8 Urinary tract infections in children 28 3.8.1 Epidemiology, aetiology and pathophysiology 28 3.8.2 Classification systems 28 3.8.2.1 Classification according to site 28 3.8.2.2 Classification according to episode 29 3.8.2.3 Classification according to severity 29 3.8.2.4 Classification according to symptoms 29 3.8.2.5 Classification according to complicating factors 29 3.8.3 Diagnostic evaluation 29 3.8.3.1 Medical history 29 3.8.3.2 Clinical signs and symptoms 30 3.8.3.3 Physical examination 30 3.8.3.4 Urine sampling, analysis and culture 30 3.8.3.4.1 Urine sampling 30 3.8.3.4.2 Urinalysis 31 3.8.3.4.3 Urine culture 31 3.8.3.5 Imaging 31 3.8.3.5.1 Ultrasound 31 3.8.3.5.2 Radionuclide scanning 32 3.8.3.5.3 Voiding cystourethrography 32 3.8.3.6 Bladder and bowel dysfunction 32 3.8.4 Management 32 3.8.4.1 Administration route 32 3.8.4.2 Duration of therapy 32 3.8.4.3 Antimicrobial agents 33 3.8.4.4 Chemoprophylaxis 35 PAEDIATRIC UROLOGY - UPDATE MARCH 2016 3 3.8.4.5 Monitoring of UTI 36 3.8.5 Summary of evidence and recommendations for the management of UTI in children 36 3.9 Day-time lower urinary tract conditions 37 3.9.1 Epidemiology, aetiology and pathophysiology 37 3.9.2 Classification systems 37 3.9.2.1 Filling-phase dysfunctions 37 3.9.2.2 Voiding-phase (emptying) dysfunctions 38 3.9.3 Diagnostic evaluation 38 3.9.4 Management 38 3.9.4.1 Standard therapy 38 3.9.4.2 Specific interventions 39 3.9.5 Summary of evidence and recommendations for the management of day-time lower urinary tract conditions 39 3.10 Monosymptomatic enuresis 39 3.10.1 Epidemiology, aetiology and pathophysiology 39 3.10.2 Classification systems 40 3.10.3 Diagnostic evaluation 40 3.10.4 Management 40 3.10.4.1 Supportive treatment measures 40 3.10.4.2 Alarm treatment 40 3.10.4.3 Medication 40 3.10.5 Summary of evidence and recommendations for the management of monosymptomatic enuresis 41 3.11 Management of neurogenic bladder 42 3.11.1 Epidemiology, aetiology and pathophysiology 42 3.11.2 Classification systems 42 3.11.3 Diagnostic evaluation 43 3.11.3.1 Urodynamic studies 43 3.11.3.1.1 Method of urodynamic study 43 3.11.3.1.2 Uroflowmetry 43 3.11.3.2 Cystometry 44 3.11.4 Management 44 3.11.4.1 Investigations 45 3.11.4.2 Early management with intermittent catheterisation 45 3.11.4.3 Medical therapy 46 3.11.4.4 Management of bowel incontinence 46 3.11.4.5 Urinary tract infection 46 3.11.4.6 Sexuality 47 3.11.4.7 Bladder augmentation 47 3.11.4.8 Bladder outlet procedures 47 3.11.4.9 Continent stoma 47 3.11.4.10 Total bladder replacement 47 3.11.5 Follow-up 48 3.11.6 Summary of evidence and recommendations for the management of neurogenic bladder 48 3.12 Dilatation of the upper urinary tract (UPJ and UVJ obstruction) 49 3.12.1 Epidemiology, aetiology and pathophysiology 49 3.12.2 Diagnostic evaluation 49 3.12.2.1 Antenatal ultrasound 49 3.12.2.2 Postnatal ultrasound 49 3.12.2.3 Voiding cystourethrogram 49 3.12.2.4 Diuretic renography 49 3.12.3 Management 50 3.12.3.1 Prenatal management 50 3.12.3.2 UPJ obstruction 50 3.12.3.3 Megaureter 50 3.12.3.3.1 Non-operative management 50 3.12.3.3.2 Surgical management 51 3.12.4 Conclusion 51 4 PAEDIATRIC UROLOGY - UPDATE MARCH 2016 3.12.5 Summary of evidence and recommendations for the management of UPJ-, UVJ-obstruction 51 3.13 Vesicoureteric reflux 51 3.13.1 Epidemiology, aetiology and pathophysiology 51 3.13.2 Diagnostic evaluation 52 3.13.2.1 Infants presenting because of prenatally diagnosed hydronephrosis 53 3.13.2.2 Siblings and offspring of reflux patients 53 3.13.2.3 Recommendations for paediatric screening of VUR 54 3.13.2.4 Children with febrile urinary tract infections 54 3.13.2.5 Children with lower urinary tract symptoms and vesicoureteric reflux 54 3.13.3 Disease management 54 3.13.3.1 Non-surgical therapy 54 3.13.3.1.1 Follow-up 54 3.13.3.1.2 Continuous antibiotic prophylaxis 55 3.13.3.2 Surgical treatment 55 3.13.3.2.1 Subureteric injection of bulking materials 55 3.13.3.2.2 Open surgical techniques 56 3.13.3.2.3 Laparoscopy and robot- assisted 56 3.13.4 Summary of evidence and recommendations for the management of vesicoureteric reflux in childhood 56 3.14 Urinary stone disease 58 3.14.1 Epidemiology, aetiology and pathophysiology 58 3.14.2 Classification systems 59 3.14.2.1 Calcium stones 59 3.14.2.2 Uric acid stones 60 3.14.2.3 Cystine stones 60 3.14.2.4 Infection stones (struvite stones) 60 3.14.3 Diagnostic evaluation 61 3.14.3.1 Imaging 61 3.14.3.2 Metabolic evaluation 61 3.14.4 Management 62 3.14.4.1 Extracorporeal shock wave lithotripsy 63 3.14.4.2 Percutaneous nephrolithotomy 63 3.14.4.3 Ureterorenoscopy 64 3.14.4.4 Open or laparoscopic stone surgery 64 3.14.5 Summary of evidence and recommendations for the management of urinary stones 65 3.15 Obstructive pathology of renal duplication: ureterocele and ectopic ureter 66 3.15.1 Epidemiology, aetiology and pathophysiology 66 3.15.1.1 Ureterocele 66 3.15.1.2 Ectopic ureter 66 3.15.2 Classification systems 66 3.15.2.1 Ureterocele 66 3.15.2.1.1 Ectopic (extravesical) ureterocele 66 3.15.2.1.2 Orthotopic (intravesical) ureterocele 66 3.15.2.2 Ectopic ureter 67 3.15.3 Diagnostic evaluation 67 3.15.3.1 Ureterocele 67 3.15.3.2 Ectopic ureter 67 3.15.4 Management 68 3.15.4.1 Ureterocele 68 3.15.4.1.1 Early treatment 68 3.15.4.1.2 Re-evaluation 68 3.15.4.2 Ectopic ureter 69 3.15.5 Summary of evidence and recommendations for the management of obstructive pathology of renal duplication: ureterocele and ectopic ureter 69 3.16 Disorders of sex development 70 3.16.1 Epidemiology, aetiology and pathophysiology 70 3.16.1.1 Micropenis 70 3.16.2 Diagnostic evaluation 70 PAEDIATRIC UROLOGY - UPDATE MARCH 2016 5 3.16.2.1 The neonatal emergency 70 3.16.2.1.1 Family history and clinical examination 70 3.16.2.1.2 Choice of laboratory investigations 71 3.16.2.2 Gender assignment 71 3.16.2.3 Role of the paediatric urologist 72 3.16.2.3.1 Clinical examination 72 3.16.2.3.2 Investigations 72 3.16.3 Management 73 3.16.3.1 Feminising surgery 73 3.16.3.2 Masculinising surgery 73 3.16.4 Summary of evidence and recommendations for the management of disorders of sex development 74 3.17 Posterior urethral valves 74 3.17.1 Epidemiology, aetiology
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  • Multiple Congenital Genitourinary Anomalies in a Polled Goat

    Multiple Congenital Genitourinary Anomalies in a Polled Goat

    Multiple Congenital Genitourinary Anomalies in a Polled Goat WILLIAM W. KING, DVM, PHD, DIPLOMATE, ACLAM,1,2* MELVIN E. YOUNG,1 AND M. EUGENE FOX, DVM3 A 1-day-old, Toggenburg/Nubian crossbred goat of polled parentage was referred for necropsy because of a large (diameter, 5 cm) bladder-like mass protruding from the perineal midline and difficult urination. Differential diagnoses included cutaneous cyst, ectopic urinary bladder, and urethral diverticulum/dilatation. Several genitourinary aberrations were noted. A second, smaller (diameter, 1 cm), more distal cystic structure was adjacent to an ambiguous prepuce. Testicles were discovered within a con- stricted, subcutaneous space near the inguinal canals. A rudimentary penis was located dorsal to the penile urethra with no appreciable urethral process. A tiny external urethral orifice was discerned only after liquid was injected into the lumen of the cystic structures, confirming their identity as urethral dilatations. The dilatations were separated by a constricting band of fibrous tissue. No other significant findings were detected. This case illustrates a combination of congenital anomalies including bilateral cryptorchidism with scrotal absence, segmental urethral hypoplasia, and urethral dilatation, most likely associated with the intersex condition seen in polled breeds. The continued production and use of small ruminants as animal models demands the prompt recognition of congenital anomalies. This case also exemplifies the precautions required when breeding goats with polled ancestry. The domestic goat (Capra hircus) has historically served and Nubian/Toggenburg sire. The owner reported that the doe had continues to play an important role in biomedical research (1). completed a normal gestation period on a diet of natural grass/ Many small breeds are available, facilitating common labora- alfalfa hay and water.