Education And Debate


BMJ 1996; 312 doi: (Published 18 May 1996) Cite this as: BMJ 1996;312:1291
  1. Chris Dawson,
  2. Hugh Whitfield


    Phimosis is the most common reason for circumcision, although recurrent balanitis is also an indication. Circumcision may also be performed for religious or social reasons.

    At birth, adhesions are present between the glans penis and the foreskin, but separation begins to occur immediately and continues thereafter. The prepuce normally becomes retractile after the age of 2 years, but many adolescent boys retain some adhesions. Preputial adhesions are a common reason for referral to a urologist, but adhesions are normal and should be treated only if they persist into adolescence and cause problems with masturbation or sexual intercourse. A non-retractile foreskin is free of symptoms and self limiting, and circumcision is not needed. Parents often say that the prepuce “balloons” when the child urinates, but this is a sign of a non-retractile foreskin rather than phimosis. Careful examination will show that the urethral meatus is visible through the narrowed preputial opening, and with time this opening widens to allow the foreskin to retract normally. True phimosis is rare but may cause appreciable problems in either childhood or adolescence. Treatment is usually circumcision.

    Possible indications for circumcision for phimosis

    • Recurrent infection under the foreskin

    • Appreciable restriction to urine flow

    Undescended testis

    The incidence of undescended testis after the first year of life is under 1%. It is not clear why testes fail to descend into the scrotum, but recent evidence suggests that descent occurs in two distinct phases and that androgens may have an important role, possibly acting via the genitofemoral nerve. In 80% of cases the undescended testis will be palpable in the inguinal canal.


    Investigation and management of undescended testis.

    If the testis is palpable in the inguinal canal then orchidopexy should be carried out. The correct timing of orchidopexy has been debated. Spontaneous descent of undescended testis is rare after the age of 1 year, and the fertility of the testis becomes compromised after the age of 2 years.

    Every attempt should be made to locate an impalpable testis. As complete absence of the testis is uncommon, an impalpable testis must be assumed to be intra-abdominal or too high in the inguinal canal for easy palpation. It is important to determine whether the missing testis was ever palpable in the scrotum.

    Ultrasonography and magnetic resonance imaging have both been used in the past to investigate the absence of the testis, but laparoscopy is now the investigation of choice. If the spermatic cord is present but no testis is found or the spermatic cord and testis are both absent then further searching is unnecessary. The patient and his parents should be counselled. Hormone replacement and a testicular prosthesis may be needed.

    Sites of undescended testis

    • Inguinal canal (80%)

    • Intra-abdominal

    • Suprapubic

    • Femoral

    • Perineal

    • Contralateral scrotum

    If an intra-abdominal testis is found before the age of 2 years then it may remain capable of spermatogenesis and microvascular orchidopexy should be tried. After the age of 2 years the undescended testis is likely to be sterile. Orchidectomy may be needed but should not be performed before puberty because of the problems associated with low concentrations of testosterone. After puberty an intra-abdominal testis should be removed as it is certain to be incapable of spermatogenesis and the risk of malignancy is up to 10 times that in a normal testis. Hormone replacement is unlikely to be needed, but the patient may need a testicular prosthesis for psychological reasons.

    Retractile testis

    • Retractile testis is a common problem in general practice but does not need to be treated

    • It is easily manipulated into the scrotum, which develops normally in this condition

    • These two points help to differentiate the retractile testis from a true undescended testis

    • The retractile testis usually descends spontaneously into the scrotum with no adverse sequelae

    Vesicoureteric junction reflux

    In the neonatal period reflux is likely to be due to anatomical abnormalities; the incidence of reflux is equal in the sexes. In later childhood the condition predominantly occurs in girls with voiding disturbances. Much evidence now exists that reflux is not a condition that should be considered in isolation and that dysfunctional voiding has a large role in the development of symptoms. A vicious cycle of symptoms may also exist because reflux may lead to infection, which itself may lead to bladder instability, dysfunctional voiding, and further reflux. These three elements should therefore be considered equally in the treatment of reflux. It is now believed that reflux alone does not lead to renal damage—infection must also be present. Many urologists believe that renal damage occurs early on in the natural course of the disease and in many cases is non-progressive.


    Micturating cystogram showing vesicoureteric reflux into duplex ureters on both sides (grade V reflux on left).

    Reflux stops spontaneously in a large proportion of patients, although the degree of resolution is inversely proportional to the severity of the reflux. All children who present with reflux should therefore be managed conservatively initially as many will settle without further treatment. Trimethoprim in a prophylactic dose given nightly may help to control infections but can usually be stopped after the age of 5 years and used to treat sporadic infections only. Dysfunctional voiding due to bladder instability should be treated with anticholinergic agents.

    Recent advances

    • In the past, treatment for reflux has centred on ureteric reimplantation

    • Recently endoscopic injection of Teflon into the submucosa of the ureter has been used with some success

    • Concern about the risks of migration of Teflon particles has prevented universal acceptance of the technique

    • Other agents, such as collagen paste, have been suggested for injection


    Hypospadias is a congenital condition affecting 3 in 1000 male infants resulting in underdevelopment of the urethra.

    The penis may be deviated by chordee, and the urethral opening may be situated anywhere from the perineum to the glans. The child should be referred to a urologist for assessment and treatment.

    Neonatal hydronephrosis

    The use of routine ultrasound examination in pregnancy has identified a number of fetuses with hydronephrosis. Until recently the correct management and the results of treatment presented a dilemma for urologists. A recent review of such cases by Dhillon has suggested a protocol for treatment. All neonates diagnosed with prenatal hydronephrosis should have an ultrasound examination in the first seven days of life. Treatment can be stratified according to the degree of dilatation. Neonates with severe hydronephrosis (>20 mm in diameter) are most likely to need surgery. Moderate (15-19 mm) and mild (<15 mm) hydronephrosis can usually be safely followed by ultrasound examination and isotope renography.

    Further studies are needed to confirm the effects of such management on long term renal function.


    Prenatal ultrasonogram of fetus showing bilateral hydronephrosis.

    Obstruction of pelviureteric junction

    The essential defect seems to be an aperistaltic segment of ureter from which the normal musculature is congenitally absent. The role of “aberrant” vessels causing obstruction has recently been questioned. These vessels are usually normal variants, often pass behind the ureter, and are not generally thought to cause obstruction.

    Presentation of obstruction

    • Obstruction of the pelviureteric junction may occur at any time (before birth, in childhood, or in adulthood)

    • Infants typically present with an abdominal mass

    • Older children may have abdominal pain

    • The condition often presents with haematuria after fairly minor abdominal trauma

    The condition is usually diagnosed by intravenous urography, which shows delay in appearance of contrast on the affected side and dilated renal pelvis and calices. The ureter, if seen, is usually not dilated. Differential renal function and confirmation of obstruction should be obtained with isotope renography.

    Surgery is indicated for obstructive symptoms, stone formation, recurrent urinary infection, or progressive renal impairment. Pyeloplasty is the treatment of choice, but if the affected kidney possesses less than 10% of total renal function a nephrectomy should be performed.

    Tumours Wilms's tumour


    Computed tomogram showing bilateral Wilms's tumours.

    The most common presentation of Wilms's tumour is with an abdominal mass, although haematuria is the presenting feature in up to 15% of cases. The diagnosis of a renal tumour is initially made either by renal ultrasonography (showing a solid lesion of the kidney) or by intravenous urography (showing distortion and displacement of the calices on the affected side). It is important at this stage to visualise adequately the other kidney because Wilms's tumour may be present in both kidneys simultaneously in up to 1 in 10 cases. A computed tomogram should be performed before surgery to determine whether vascular involvement, particularly of the inferior vena cava, has occurred.

    Wilms's tumour is treated by radical nephrectomy, and chemotherapy is usually given after surgery, the exact protocol depending on the stage of the disease. Radiotherapy is needed only if tumour has been left behind at surgery or for lymphatic and pulmonary metastases.

    Wilms's tumour

    • Most common urinary malignancy in children

    • Incidence of 7 per million children a year

    • Of children with Wilms's tumour, about 15% have congenital abnormalities, including musculoskeletal and other genitourinary anomalies (4.4%)

    Renal cell carcinoma

    This tumour is rare in children and is not usually diagnosed until confirmed by histological examination of a presumed Wilms's tumour. Chemotherapy and radiotherapy are equally ineffective, and radical nephrectomy remains the only treatment.


    This sarcoma commonly presents with lower urinary tract symptoms, particularly haematuria or urinary retention. Tumours of the vagina may cause a foul vaginal discharge, and pelvic tumours may cause a large mass.

    Radical surgery has been shown to be effective in the treatment of rhabdomyosarcoma. More recently chemotherapy and radiotherapy have been tried in an attempt to avoid removal of the bladder.


    Intravenous urogram showing rhabdomyosarcoma of bladder causing bilateral hydronephrosis.

    Key references

    Bianchi A. The impalpable testis. Ann R Coll Surg Engl 1995;77:3-6

    Dhillon HK. Imaging and follow up of neonatal hydronephrosis. Current Opinion in Urology 1995;75:75-8

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