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Home , Interstitial cystitis, Meatal stenosis, Urachal cyst

Central Annals of Pediatrics & Child Health

Mini Review *Corresponding author Ahmed M Eliwa, Department, Faculty of medicine Zagazig University, Zagazig , Egypt, Tel: Urological Causes of Abdomi- 00201018119977; Email: Submitted: 25 January 2016 Accepted: 05 April 2016 nal Pain in Children: A Mini- Published: 07 April 2016 Copyright Review © 2016 Eliwa OPEN ACCESS Ahmed M Eliwa* Department of Urology and Andrology, Zagazig University, Egypt Keywords • Urological • Abdominal pain Abstract • Children Abdominal pain is a common presentation to a various abdominal and extra- abdominal diseases in children.Most of urologic disorders may present in children with abdominal pain yet, their presentation may be atypical and confusing. Pediatrician and primary care giver must have high index of suspicion for these disorders. Good interpretation of the clinical manifestation and appropriate acquisition of suitable laboratory and radiologic investigations are the keys to accurate diagnosis of an abnormality in the child’surogenital tract.Urological disorders that may cause abdominal pain in children may include some common disorders such as: -urinary tract obstruction and hydronephrosis –urinary tract infections –tumors and trauma of the urinary tract –other conditions.

INTRODUCTION torsion of the testis. Referredscrotal pain may arise in the kidneys or retroperitoneum. Abdominal pain in children is in one of the most important symptom in clinical practice as it represents a wide plethora of Etiology and Management of urologic abdominal pain causes and predisposing factors that may be attributed to either a in children local cause or even a systematic cause. It is important to mention An overview: that abdominal paina common presentation of various urologic diseases in children (which in turn are common in children). An A. Hydronephrosis and Urinary Tract Obstruction important issue to state is that abdominal pain in children due to B. Urinary tract infections [UTIs] urologic cause may differ in clinical presentation and course than in adults, that’s to say that urologic abdominal pain may have C. Urinary tract trauma a non-classical presentation.Another critical issue to consider D. Tumours of the urinary tract is that pain in the genitalia (due to torsion or orchitis) may be referred to the abdominal and vice versa hence workup of a E. Genital tract abnormalities case of abdominal pain should include genital thorough genital F. Other Causes examination.Primary care physician or care provider must have a A. Hydronephrosis and Urinary Tract Obstruction high index of suspicion to identify a urologic cause for abdominal Urinary stone disease in children pain. Urinary stone disease is the most common cause of urologic Types and classification of urologic abdominal pain abdominal pain. Abdominal pain due to Upper urinary tract Renal Pain: It is located in the ipsilateralcostovertebral adults. In many cases the condition may present with vague upperabdomen and umbilicus and may be referred to the testis or abdominalstone in children pain, recurrent may differ UTI, lower than urinary the classic tract flank symptomand pain in labium.angle the Association pain may radiate with gastrointestinalsymptoms across the flank anteriorly is towardcommon the ., which occurs in approximately 40–75% of children with urolithiasis [1,2] presents with a sudden onset Bladder Pain: Produced either by bladder distension or with gastrointestinalsymptoms (nausea and vomiting). of severe cramp-likeflank, abdominal, or associated bladderTesticular . Pain: Scrotal pain is either primary or referred. Irritativevoiding symptoms (i.e. urgency, andfrequency) occur Primary scrotal pain is usually due to acute epididymitis or when the calculus is in the distalthird of the . In some

Cite this article: Eliwa AM (2016) Urological Causes of Abdominal Pain in Children: A Mini-Review. Ann Pediatr Child Health 4(1): 1097. Eliwa (2016) Email: Central patients the pain canpresent as diffuse abdominal pain and can causeof neonatal hydronephrosis. They usually affect male boys and occur on the left side [15,16]. Clinical presentation includes recurrent UTI, hematuria, and abdominal mass or (76%).obscurethe Other clinical symptomsincluded picture, delaying gross the correct hematuria diagnosis (15%) [3]. of cyclic abdominal pain. Diagnostic Work up includes ultrasound, Sternberg et al found that frequent symptoms were loin patients voiding cystourethrography, dynamicnuclear renography and urethrocystoscopy in some cases.Treatment is by surgical patients and concurrenturinary tract infection (UTI) in (8%) of patientsInitial [4]. investigation includes pelvi-abdominal ultrasound, urinalysis and KUB. The most sensitive testfor identifying stones ureteralVesicoureteral tailoring and reflux anti-reflux [VUR] re-implantation in the is non-contrast helical computerized tomography scanning. It is safe and rapid, with 97%sensitivity is an anatomical and/or functional in children, butmay be needed to delineate the calyceal anatomy. disorder that lead to retrograde flow of from the urinary Nonand 96%contrast specificity computerized [5-7]. Intravenous tomography pyelography [NCCT] can is rarelydetermine used this condition may lead to serious consequences, suchas renal scarringbladder to [due the to ureter repeated with pyelonephritis], or without the hypertension,kidney.in children and stone density and skin-to-stone distance; all of whichhave not develop renal scars and probably do not need anyintervention an impact on extracorporeal shock wave lithotripsy (ESWL) [17].renal VURfailure. in childrenFortunatelygood has an incidence proportion of ofnearly reflux 1%.The patients Classic does outcome [8-11]. The disadvantage of non-contrastCT is the age of presentationoccurs in school children. They present disease.Treatmentabsent quantification options of renal includes functions, conservative as well as high management radiation. Metabolic workup is mandatory in children with urinary stone imaging tests include renal and bladder ultrasonography, voidingwith abdominal cystourethrography pain as a prime [VCUG] symptom and nuclear [18]. The renalscans.A standard laparoscopic[fluids and medical . expulsive therapy], [ESWL], percutaneous baselinerenal isotope scan using dimercaptosuccinic acid [DMSA] nephrolithotomy [PCNL], ureteroscopy [URS], and open or scan atthe time of diagnosis can be used for detection of renal Pelvi-ureteric Junction obstruction [PUJO]

PUJO is the most common cause of congenital urinary scarring and later during follow-up [19,20]. The treatment tract obstruction in children. The obstructing factors may [endoscopiclines for VUR injection includes of bulking non-surgical agent or treatment surgical ureterovesical [follow up or reimplantation].continuous prophylaxis] or surgical correction the pelvi-ureteric junction. Secondary causes of PUJO such as include fibrous band, adynamic segment or crossing vessel at Urinary tract obstructions at other levels congenital hydronephrosis are diagnosed during the prenatal stone, polyp, or stricture may be present. Most of children with Urinary tract obstructions at other levels, such as clinical presentation is abdominal pain and recurrent UTI. bladderoutlet or the [, congenital ultrasonographic imaging during pregnancy [12]. The usual ] may cause abdominal pain. PUJO is one of the common causes of recurrent abdominal B. Urinary tract infections [UTIs] and includes episodic, upper abdominalcrampy pain, nausea, and Urinary tract infections (UTIs) are the most common bacterial pain in children. Dietl’s crisiswas described by Josef Dietl in1864, (Table 1), especially considering age, gender, pathogenand vomiting associated with intermittent renal pelvic obstruction infection in children [21-23]. Clinical presentation is variable [13]. Recurrent abdominal pain ceases after surgical correction children depends on adequate clinical evaluation [through history of theThe PUJO preliminary [14]. diagnostic method is pelviabdominal anatomical malformations [24-27]. The diagnosis of UTI in ultrasonography. Ultrasonography can detect degree of hydronephrosis, antero-posterior diameter of the renal , and examination], urinalysis and urine culture and sensitivity. parenchymal thickness and echogenicity. Doppler US can be Table 1: Clinical presentation of UTI according to site. Upper urinary tract Lower urinary tract (Cystitis) to demonstrate crossing vessel at the pelvi-ureteric junction. used to calculate renal artery resistive index and can be used (pyelonephritis) Diffuse pyogenic infection of the important tool of diagnosis. Split kidney function, GFR, Renal renal pelvis and parenchyma mucosa Diuretic Radio-isotope renography [with 99mTc-MAG3] is isotope uptake curve and time, all are information obtained InflammatoryDysuria, frequency, condition urgency, of the chills, costovertebral angle or malodorous urine, enuresis, includes open pyeloplasty or laparoscopic pyeloplasty. Other • Abrupt onset Fever (>38°C), • hematuria, and suprapubic pain by this technique.Surgical treatment of PUJO [when indicated] Cystitis symptoms in older flank pain, and tenderness. options of treatment include watchful waiting and endoscopic • pain. children along with fever/flank incisionMegaureter [Endopyelotomy]. and Ureterovesical junction (UVJ) Infants and children may have obstruction • poor appetite, failure to thrive, Ureterovesical junction (UVJ) obstruction is an obstructive lethargy,non-specific irritability, signs such vomiting as or condition at the distal ureter as it entersthe bladder [obstructive diarrhea ]. Megaureters are the second most common Data obtained from references [28-30] Ann Pediatr Child Health 4(1): 1097 (2016) 2/5 Eliwa (2016) Email: Central

Table 2: Childhood renal tumors. Rosen and coworker demonstratedthat UTI in children was Benign renal tumors Malignant renal tumours associated with developmentof chronic abdominal in children Mesoblastic nephroma [<1 year Wilm’s’ tumor and those children with a history of UTI had nearly 6times odds of age] Neuroblastoma • • of developing chronic abdominal pain compared with their Cystic nephroma Clear cell sarcoma (bone and sensitivity, abdominopelvic ultrasonography. Radioisotope Angiomyolipoma • secondaries) renographysiblings [31]. and Diagnostic voiding tools cystourethrography include urinalysis are urine indicated culture in • • • brainsecondaries) therapy. • Haemangioma/ lymphangioma • Rhabdoid tumor (bone/ some circumstances. Treatment is with appropriate antimicrobial C. Urinary tract trauma Data obtained from reference [37] abdominalpain or renal colic secondary to uretero-pelvicjunction obstruction or urolithiasis. renalKidney damage injury due toin bluntblunt abdominal abdominal trauma trauma than accounts adults forbecause 10% Urachal and sinus Urachal remnants can present theirof all blunt kidney abdominal is larger injuries in relation [32]. to Children the rest have of thehigher body risk and or as one of four primary recognized ; patent , • oftenretains fetal lobulations.It has also less protection due to less urachal sinus, vesico-urachal diverticulum, and urachal cyst. An infected urachal cyst is an important diagnosis to make as isperirenal sudden fat,deceleration weaker abdominal of the child’s muscles, body [sportand a lessaccidents, ossified falls, or elastic thoracic cage [33]. The mechanism of blunt renal trauma complications include , fistula formation, and rupture leading toPainful bladder [40,41] syndrome in children [interstitial and contact with blunt objects]. Diagnosis of renal injury with report• in children. In their series of seven trunkblunt abdominal contusions trauma and abrasions, can be suspected andhematuria. with abdominalor Contrast pelvi- flank cases,cystitis they in children]. describe theChenoweth presenting and signs Clawater and symptoms were the as:first day to abdominaltenderness, CTlower is therib goldfractures, standard fractures method or vertebral for diagnosis pedicles, and and night frequency of , abdominal pain, decreased staging of renal trauma. Treatment includes either conservative bladder capacity, negative urinalysis and culture. In addition,

and tense, resting poorly, crying frequently, and having poor managementD. Tumors or of surgical the urinary exploration. tract these children were described as being extremely nervous Wilm’s tumor accounts for 6% to 7% of all childhood cancers. Psychological non-neuropathic bladder (Hinman It isthe most common renal tumor of childhood, accounting for appetites [42]. syndrome) and dysfunctional voiding in children: Hinman described• an apparent ‘syndrome’ of voidingdysfunction that 95%of all kidney cancers in children under the age of 15 in the mimics neuropathic bladder diseasebut may be a learned encounteredUnited States in [34,35]. cases of The hemorrhage usual presentation inside the tumourof Wilm’s or tumour is painless abdominal mass. However severe pain may be rupture due to trauma. disorder [43]. It results from active contraction of the sphincter during voiding,creating a degree of outflow obstruction. ofchildhood. The tumour may arise in the retroperitoneum, Abdominal pain develops secondary to chronic constipation [44]. Neuroblastoma is the most common extracranial solid tumor Affected individuals exhibit extremely similar clinical features these tumors arise and the spectrum oftheir differentiation to those seen in individuals with Urofacial syndrome, except for adrenal, paravertebral ganglia. Thevariety of locations where abnormalitiesCrystalluria inin facial children expression, which does not occur. presenting symptoms are abdominal pain and abdominal mass Crystalluria means the presence of crystal in urinalysis. It results in a wide range of clinical presentations. The hallmark found in normal and pathological conditions. represents supersaturation of urine with this substance. It can be tothe[36]. Otherspecialist solid as benign soon as tumor possible. includes meroblastic nephroma and angiomyolipoma [Table 2]. These patients should be referred E. Genital tract abnormalities phosphate, calcium phosphate and amorphous phosphates or uratesNormal is Crystalluria caused by include transient calcium supersaturation oxalate, uric of acid, the urine,triple

Testicular Torsion should always be included in differential ofingestion cases. On of the foods, other or hand by changes pathological of urine crystalluria temperature urolithiasis, and/or diagnosis when evaluating lower abdominal pain in young males. acutepH which uric occur acid upon nephropathy, standing after ethylene micturition. glycol In a poisoning, minority The external genital organs should be examined in every child hypereosinophilic syndrome. In addition, crystalluria can be or adolescent with acute abdominal pain. The most common due to drugs such as sulphadiazine, acyclovir, triamterene, presenting• F. symptomsOther Causes are abdominal Horseshoe pain kidney and vomitinggenerally [38]. present

antiepilepticClinically drugs Crystalluria and others may [45]. be asymptomatic [especially in with vague abdominal pain. Patients can develop abdominal pain normal children] or can be discovered accidentally during routine and nausea withhyperextension of the spine (Rovsing syndrome), checkup. In contrast pathologic Crystalluria usually present presumably resulting from stretching of the isthmus [39]. the genitourinaryor gastrointestinal system, such as vague • Renal ectopia present with symptoms attributed to hem with abdominal pain, , failure to thrive or macroscopic aturia and recurrent UTI [46]. Ann Pediatr Child Health 4(1): 1097 (2016) 3/5 Eliwa (2016) Email: Central

It should be noticed that the majority of renal calculi in Gunn TR, Mora JD, Pease P. Antenatal diagnosis of urinary tract ’ gestation: incidence 12. children are comprised of either calcium oxalate or calcium abnormalities by ultrasonography after 28 weeks Idiopathic hypercalciuria and hypocitraturia are the most andDietl outcome. J: Wanderndenieren Am J Obstet Gynecol. and 1995; dereneinklemmung. 172: 479-486. Wien Med frequentlyphosphate andreported are often metabolic associated abnormalities. with a metabolic Given abnormality.the high risk 13. Wochenschr.Flotte TR. Dietl1864; syndrome:14: 153-166. intermittent ureteropelvic junction of recurrences in children with idiopathic hypercalciuria and 14. comprehensivehypocitraturia and metabolic the importance evaluation of excluding is indicated rare in but all treatablechildren obstruction as a cause of episodic abdominal pain. Pediatrics. 1988; conditions such as primary hyperoxaluria and cystinuria a 15. 82:O’ 792-794. 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Cite this article Eliwa AM (2016) Urological Causes of Abdominal Pain in Children: A Mini-Review. Ann Pediatr Child Health 4(1): 1097.

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