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Guidelines on Paediatric Urology S Guidelines on Paediatric Urology S. Tekgül (Chair), H.S. Dogan, E. Erdem (Guidelines Associate), P. Hoebeke, R. Ko˘cvara, J.M. Nijman (Vice-chair), C. Radmayr, M.S. Silay (Guidelines Associate), R. Stein, S. Undre (Guidelines Associate) European Society for Paediatric Urology © European Association of Urology 2015 TABLE OF CONTENTS PAGE 1. INTRODUCTION 7 1.1 Aim 7 1.2 Publication history 7 2. METHODS 8 3. THE GUIDELINE 8 3A PHIMOSIS 8 3A.1 Epidemiology, aetiology and pathophysiology 8 3A.2 Classification systems 8 3A.3 Diagnostic evaluation 8 3A.4 Disease management 8 3A.5 Follow-up 9 3A.6 Conclusions and recommendations on phimosis 9 3B CRYPTORCHIDISM 9 3B.1 Epidemiology, aetiology and pathophysiology 9 3B.2 Classification systems 9 3B.3 Diagnostic evaluation 10 3B.4 Disease management 10 3B.4.1 Medical therapy 10 3B.4.2 Surgery 10 3B.5 Follow-up 11 3B.6 Recommendations for cryptorchidism 11 3C HYDROCELE 12 3C.1 Epidemiology, aetiology and pathophysiology 12 3C.2 Diagnostic evaluation 12 3C.3 Disease management 12 3C.4 Recommendations for the management of hydrocele 12 3D ACUTE SCROTUM IN CHILDREN 13 3D.1 Epidemiology, aetiology and pathophysiology 13 3D.2 Diagnostic evaluation 13 3D.3 Disease management 14 3D.3.1 Epididymitis 14 3D.3.2 Testicular torsion 14 3D.3.3 Surgical treatment 14 3D.4 Follow-up 14 3D.4.1 Fertility 14 3D.4.2 Subfertility 14 3D.4.3 Androgen levels 15 3D.4.4 Testicular cancer 15 3D.5 Recommendations for the treatment of acute scrotum in children 15 3E HYPOSPADIAS 15 3E.1 Epidemiology, aetiology and pathophysiology 15 3E.1.1 Risk factors 15 3E.2 Classification systems 15 3E.3 Diagnostic evaluation 16 3E.4 Disease management 16 3E.4.1 Age at surgery 16 3E.4.2 Penile curvature 17 3E.4.3 Preservation of the well-vascularised urethral plate 17 3E.4.4 Re-do hypospadias repairs 17 3E.4.5 Urethral reconstruction 18 3E.4.6 Urine drainage and wound dressing 18 3E.4.7 Outcome 18 3E.5 Follow-up 19 3E.6 Conclusions and recommendations for the management of hypospadias 19 3F CONGENITAL PENILE CURVATURE 19 3F.1 Epidemiology, aetiology and pathophysiology 19 2 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2015 3F.2 Diagnostic evaluation 19 3F.3 Disease management 20 3G VARICOCELE IN CHILDREN AND ADOLESCENTS 20 3G.1 Epidemiology, aetiology and pathophysiology 20 3G.2 Classification systems 20 3G.3 Diagnostic evaluation 20 3G.4 Disease management 21 3G.5 Conclusions and recommendations 21 3H URINARY TRACT INFECTIONS IN CHILDREN 22 3H.1 Epidemiology, aetiology and pathophysiology 22 3H.2 Classification systems 22 3H.2.1 Classification according to site 22 3H.2.2 Classification according to episode 22 3H.2.3 Classification according to severity 23 3H.2.4 Classification according to symptoms 23 3H.2.5 Classification according to complicating factors 23 3H.3 Diagnostic evaluation 23 3H.3.1 Medical history 23 3H.3.2 Clinical signs and symptoms 23 3H.3.3 Physical examination 23 3H.3.4 Urine sampling, analysis and culture 23 3H.3.4.1 Urine sampling 23 3H.3.4.2 Urinalysis 24 3H.3.4.3 Urine culture 25 3H.3.5 Imaging 25 3H.3.5.1 Ultrasound 25 3H.3.5.2 Radionuclide scanning 25 3H.3.5.3 Voiding cystourethrography 25 3H.3.6 Bladder and bowel dysfunction 26 3H.4 Disease management 26 3H.4.1 Administration route 26 3H.4.2 Duration of therapy 26 3H.4.3 Antimicrobial agents 27 3H.4.4 Chemoprophylaxis 29 3H.4.5 Monitoring of UTI 30 3H.5 Conclusions and recommendations for UTI in children 30 3I DAYTIME LOWER URINARY TRACT CONDITIONS 31 3I.1 Epidemiology, aetiology and pathophysiology 31 3I.2 Classification systems 32 3I.2.1 Filling-phase dysfunctions 32 3I.2.2 Voiding-phase (emptying) dysfunctions 32 3I.3 Diagnostic evaluation 32 3I.4 Disease management 32 3I.4.1 Standard therapy 32 3I.4.2 Specific interventions 33 3I.5 Recommendations for the treatment of daytime lower urinary tract conditions 33 3J MONOSYMPTOMATIC ENURESIS 33 3J.1 Epidemiology, aetiology and pathophysiology 33 3J.2 Classification systems 34 3J.3 Diagnostic evaluation 34 3J.4 Disease management 34 3J.4.1 Supportive treatment measures 34 3J.4.2 Alarm treatment 34 3J.4.3 Medication 34 3K MANAGEMENT OF NEUROGENIC BLADDER IN CHILDREN 36 3K.1 Epidemiology, aetiology and pathophysiology 36 3K.2 Classification systems 36 3K.3 Diagnostic evaluation 37 3K.3.1 Urodynamic studies 37 3K.3.1.1 Method of urodynamic study 37 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2015 3 3K.3.1.2 Uroflowmetry 37 3K.3.2 Cystometry 37 3K.4 Disease management 38 3K.4.1 Investigations 38 3K.4.2 Early management with intermittent catheterisation 39 3K.4.3 Medical therapy 39 3K.4.4 Management of bowel incontinence 39 3K.4.5 Urinary tract infection 40 3K.4.6 Sexuality 40 3K.4.7 Bladder augmentation 40 3K.4.8 Bladder outlet procedures 40 3K.4.9 Continent stoma 41 3K.4.10 Total bladder replacement 41 3K.5 Follow-up 41 3L DILATATION OF THE UPPER URINARY TRACT (UPJ and UVJ Obstruction) 41 3L.1 Epidemiology, aetiology and pathophysiology 41 3L.2 Diagnostic evaluation 42 3L.2.1 Antenatal ultrasound 42 3L.2.2 Postnatal ultrasound 42 3L.2.3 Voiding cystourethrogram 42 3L.2.4 Diuretic renography 42 3L.3 Disease management 43 3L.3.1 Prenatal management 43 3L.3.2 UPJ obstruction 43 3L.3.3 Megaureter 43 3L.3.3.1 Nonoperative management 43 3L.3.3.2 Surgical management 43 3L.4 Conclusion 43 3L.4.1 Conclusions and recommendations for UPJ-, UVJ-obstruction 43 3M VESICOURETERIC REFLUX IN CHILDREN 44 3M.1 Epidemiology, aetiology and pathophysiology 44 3M.2 Diagnostic evaluation 45 3M.2.1 Infants presenting because of prenatally diagnosed hydronephrosis 46 3M.2.2 Siblings and offspring of reflux patients 46 3M.2.3 Recommendations for paediatric screening of VUR 46 3M.2.4 Children with febrile urinary tract infections 46 3M.2.5 Children with lower urinary tract symptoms and vesicoureteric reflux 47 3M.3 Disease management 47 3M.3.1 Non-surgical therapy 47 3M.3.1.1 Follow-up 47 3M.3.1.2 Continuous antibiotic prophylaxis 47 3M.3.2 Surgical treatment 47 3M.3.2.1 Subureteric injection of bulking materials 47 3M.3.2.2 Open surgical techniques 48 3M.3.2.3 Laparoscopy 48 3M.3.3 Recommendations for the management of vesicoureteric reflux in childhood 49 3N URINARY STONE DISEASE 51 3N.1 Epidemiology, aetiology and pathophysiology 51 3N.2 Classification systems 51 3N.2.1 Calcium stones 51 3N.2.2 Uric acid stones 52 3N.2.3 Cystine stones 53 3N.2.4 Infection stones (struvite stones) 53 3N.3 Diagnostic evaluation 53 3N.3.1 Imaging 55 3N.3.2 Metabolic evaluation 55 3N.4 Disease management 55 3N.4.1 Extracorporeal shock wave lithotripsy 55 3N.4.2 Percutaneous nephrolithotomy 56 3N.4.3 Ureterorenoscopy 57 4 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2015 3N.4.4 Open or laparoscopic stone surgery 57 3N.5 Conclusions and recommendations 58 3O OBSTRUCTIVE PATHOLOGY OF RENAL DUPLICATION: URETEROCELE AND ECTOPIC URETER 59 3O.1 Epidemiology, aetiology and pathophysiology 59 3O.1.1 Ureterocele 59 3O.1.2 Ectopic ureter 59 3O.2 Classification systems 59 3O.2.1 Ureterocele 59 3O.2.1.1 Ectopic (extravesical) ureterocele 59 3O.2.1.2 Orthotopic (intravesical) ureterocele 59 3O.2.2 Ectopic ureter 59 3O.3 Diagnostic evaluation 60 3O.3.1 Ureterocele 60 3O.3.2 Ectopic ureter 60 3O.4 Disease management 60 3O.4.1 Ureterocele 60 3O.4.1.1 Early treatment 61 3O.4.1.2 Re-evaluation 61 3O.4.2 Ectopic ureter 61 3O.5 Conclusions and recommendations for obstructive pathology of renal duplication: ureterocele and ectopic ureter 62 3P DISORDERS OF SEX DEVELOPMENT 63 3P.1 Epidemiology, aetiology and pathophysiology 63 3P.1.1 Micropenis 63 3P.2 Diagnostic evaluation 63 3P.2.1 The neonatal emergency 63 3P.2.1.1 Family history and clinical examination 64 3P.2.1.2 Choice of laboratory investigations 64 3P.2.2 Gender assignment 65 3P.2.3 Role of the paediatric urologist 65 3P.2.3.1 Clinical examination 65 3P.2.3.2 Investigations 65 3P.3 Disease management 66 3P.3.1 Feminising surgery 66 3P.3.2 Masculinising surgery 66 3P.4 Guidelines for the treatment of disorders of sex development 67 3Q POSTERIOR URETHRAL VALVES 67 3Q.1 Epidemiology, aetiology and pathophysiology 67 3Q.2 Classification systems 67 3Q.2.1 Urethral valve 67 3Q.3 Diagnostic evaluation 68 3Q.4 Disease management 68 3Q.4.1 Antenatal treatment 68 3Q.4.2 Postnatal treatment 68 3Q.5 Follow-up 69 3Q.6 Summary 70 3Q.6.1 Conclusions and recommendations posterior urethral valves 71 3R PAEDIATRIC UROLOGICAL TRAUMA 71 3R.1 Paediatric renal trauma 71 3R.1.1 Epidemiology, aetiology and pathophysiology 71 3R.1.2 Classification systems 72 3R.1.3 Diagnostic evaluation 72 3R.1.3.1 Haematuria 72 3R.1.3.2 Blood pressure 72 3R.1.3.3 Choice of imaging method 72 3R.1.4 Disease management 72 3R.1.5 Recommendations for the diagnosis and treatment of paediatric renal trauma 73 3R.2 Paediatric ureteral trauma 73 3R.2.1 Diagnostic evaluation 73 PAEDIATRIC UROLOGY - LIMITED UPDATE MARCH 2015 5 3R.2.2 Disease management 73 3R.2.3 Recommendations for the diagnosis and treatment of paediatric ureteral trauma 74 3R.3 Paediatric bladder injuries 74 3R.3.1 Diagnostic evaluation 74 3R.3.2 Disease management 74 3R.3.2.1 Intraperitoneal injuries 74 3R.3.2.2 Extraperitoneal injuries 74 3R.3.3 Recommendations for the diagnosis and treatment of paediatric bladder injuries 75 3R.4 Paediatric urethral injuries 75 3R.4.1 Diagnostic evaluation 75 3R.4.2 Disease management 75 3R.4.3 Guidelines for the diagnosis and treatment of paediatric trauma 76 3S POST-OPERATIVE FLUID MANAGEMENT 76 3S.1 Epidemiology, aetiology and pathophysiology 76 3S.2 Disease management 76 3S.2.1 Pre-operative fasting 76 3S.2.2 Maintenance therapy and intra-operative fluid therapy 76 3S.2.3 Post-operative fluid management 78 3S.2.4 Post-operative fasting 78 3S.3 Summary conclusions and recommendations 78 3T POST-OPERATIVE PAIN MANAGEMENT IN CHILDREN: GENERAL INFORMATION 79 3T.1 Epidemiology, aetiology and pathophysiology 79 3T.2 Diagnostic evaluation 79 3T.3 Disease management 79 3T.3.1 Drugs and route of administration 79 3T.3.2 Circumcision 82 3T.3.3 Penile, inguinal and scrotal surgery 82 3T.3.4 Bladder and kidney surgery 82 3T.4 Conclusions and recommendations 83 4.
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