Pediatric urology is a surgical subspecialty of medicine dealing with the disorders of children’s genitourinary systems. Pediatric urologists provide care for both boys and girls ranging from birth to early adult age. The most common problems are those involving disorders of urination, reproductive organs and testes.
The decision to perform a VCUG in a child with a first-time febrile UTI continues to raise controversy. The current AAP guidelines indicate that, in children from 2 months to 2 years with a normal renal ultrasound, a VCUG may not be needed on the first infection. This is based on the conclusion that treatment of VUR, if found on a VCUG, using prophylactic antibiotics is not effective; therefore, the search for VUR serves little clinical benefit. These conclusions have been disputed by the AAP Section on Urology and the AUA guideline for VUR. This new approach also assumes close and continuous follow-up of children, which is not always the reality. In the perfect world, this approach is likely safe; but, in practice, it seems that pediatricians are generalizing this to older children in whom there is no evidence that it is appropriate, and they are often waiting for several UTIs before referring the child to imaging.
Diagnostic ultrasound is often ordered by primary care providers for boys with a non-palpable testis; yet, there are clear data that this does not change the management, and it offers little clinical benefit. A good clinical examination that does not find a testis suggests that some procedure will be needed in that child, since no imaging study has been shown to be 100% sensitive for an absent testis. With the widespread use of diagnostic and therapeutic laparoscopy for undescended testes, the role for ultrasound is limited. We would use ultrasound of the groin only for obese boys in whom a clinical examination is difficult, as an inguinal testis would not require laparoscopy.
The age for hypospadias repair has continued to decline but has settled between 4 and 12 months. Our preference is to perform these repairs at 6 months in most cases of healthy children. Some practitioners will recommend repair at 4 months, but there are differences of opinion as to the risks of anesthesia under 6 months. In nearly all situations, the repair should be performed before 1 year of age as the child recovers more quickly, seems to have less morbidity, and is not as mobile as after 1 year.