Pediatric Urology Services in San Antonio, New Braunfels, & South Texas

Vesicoureteral reflux (VUR) is one of the most common conditions for which we see children. Up to one-third of children with Urinary Tract Infection (UTI) have VUR. It is usually discovered due to UTIs but can also be discovered incidentally or due to kidney dilation (hydronephrosis) noted on prenatal ultrasound. Many children will “outgrow” VUR with time (spontaneous resolution). For children with normal bladder function, VUR itself is not harmful to the kidney. However, the presence of VUR increases the risks of UTIs until it resolves or is surgically corrected. Most children are maintained on a low-dose once-daily prophylactic (preventative) antibiotic until the VUR resolves or is corrected or becomes very minimal. VUR can be one-sided or both sided and varies in severity. The more severe it is, the higher the risk of UTI problems, and the longer it will likely take before the VUR resolves. We will discuss your child’s VUR grade and the risk of UTIs at each visit. Additionally, we will discuss your child’s bowel and bladder habits, which are strongly related to VUR resolution and UTI problems.

We treat hundreds of children with VUR of all varieties and severities each year. Each child with VUR is different, and there is no “one size fits all” treatment plan for this condition. At each visit, options for continued treatment are discussed, including the pros/cons of each option. Parental preferences are extremely important for managing this condition, as there are usually several good treatment options available. We strive to provide parents with an honest assessment of their child’s risk of UTIs and the likelihood of VUR resolution, along with reasonable treatment options. A decision is then made together, with parental preferences as the primary driver of the treatment plan.

We perform hundreds of VUR correction procedures (under anesthesia) each year, from minimally invasive procedures using a scope (no incisions) inserted into the bladder through the urethra to open bladder surgery through a small “bikini” incision. The decision of when to proceed to surgery and which procedure is best for your child will also be made together, with parental preferences at the foremost of the decision.

Continence problems in children are extremely common. Many primary care providers are comfortable and willing to address them. However, sometimes these problems are refractory to routine interventions or are persistent and complicated. We see children with continence problems, daytime, nighttime, and both, from complex to simple, every day. Evaluations will include the evaluation of a urine specimen to rule out urinary tract infections or blood in the urine and an ultrasound to ensure good bladder emptying. Most importantly, a thorough history will be obtained, and a physical exam will be performed. The history is usually the most important factor in the evaluation of children with incontinence. We will ask many questions at these visits, including how often the child voids, when the incontinence occurs, how much urine is leaked, treatments that have been tried previously, whether urinary tract infections are occurring as well, and for how long the incontinence has been occurring. We will also ask about bowel movement frequency, consistency and any incontinence of stool. The more information or detail the parents (and the child in older children) can give us, the more quickly we can pinpoint the cause of the incontinence and provide the correct recommendations, treatments and sometimes medications to achieve continence. If your child is seeing us for incontinence, please be prepared to answer these questions with as much detail as possible.

Continence problems can be some of the most frustrating for both parents and children. As physicians who only treat children, we understand these frustrations and provide compassionate assessments, treatment recommendations and ongoing follow-up to help your child achieve continence.

Bladder stones are quite rare, especially in children. The development of stone(s) in the bladder is always related to incomplete emptying of the bladder (stasis of urine). They are extremely rare in neurologically normal children. They are most commonly seen in children with neurogenic bladder, which means abnormal bladder function due to a neurological problem. The most common cause of neurogenic bladder in children is spina bifida and associated similar congenital anomalies.

Bladder stones will almost always require surgery for removal. Today, this is almost always possible with a minimally invasive technique, usually with a small scope passed through the urethra or via a small incision just above the bladder through which a scope is passed. The stones can then be removed with the scope and/or fragmented with a laser. It is rare to require an “open” procedure for the removal of bladder stones today.

Neurogenic bladder (NGB) refers to abnormal bladder function due to a neurological problem. In children, this is most commonly seen due to spina bifida. There are also many other spinal cord problems in children that can lead to the development of NGB, including tethered cord, lipomeningocele, syrinx, etc. Unfortunately, the type of neurological problem or spinal cord level is rarely helpful in predicting the degree or type of bladder function problems that will be found. These bladder problems can include failure to store urine at safe/low pressure, failure to empty with voiding, reflux of urine back up into the kidney(s), spasticity of the bladder (unwanted contractions of the bladder at random times) and incontinence of urine. Untreated NGB can lead to various serious problems, including kidney damage, incontinence, recurrent urinary tract infections and bladder stones.

Therefore, we focus our evaluation and treatment of children with NGB on an individualized assessment of each child’s specific bladder function. The mainstay of these evaluations, in addition to a history and physical exam, includes regular kidney/bladder ultrasounds and periodic urodynamic testing. Urodynamic testing involves placing small catheters into the bladder and rectum to measure as much as possible about bladder function, including volume the bladder holds, pressure inside the bladder during filling, evaluation of voiding (peeing) and spasticity (abnormal contractions during slow filling). Urodynamics can be scary and uncomfortable for some children who are not already accustomed to regular catheterization. We perform these tests every day in our office, with experienced staff and nurses who are well aware of the anxieties and concerns children have with such an exam. Our urodynamic suite is “kid-friendly,” including a DVD player and selection of children’s movies. Most children tell us, “that wasn’t as bad as I thought,” when the exam is complete!  Rest assured, we will do everything possible to alleviate stress and anxiety if urodynamics is needed for your child’s assessment.

Because each child with NGB has different and individual bladder function problems, social/family situations or other medical conditions, we tailor the treatment of children with NGB individually. Your physician will review the findings of the evaluations and then discuss treatment options.

Our goals for the treatment of children with NGB involves a three-tiered overall approach:

1. Ensure bladder function is safe to prevent kidney damage.
2. Minimize or eliminate urinary tract infections.
3. Help children and families motivated to achieve continence do so. In some cases, surgery will be required to reach these goals. If this is the case, please know that as fellowship-trained pediatric urologists, we have extensive experience with the full spectrum of procedures that can be needed, including continent catheterizable channels (appendicovesicostomy/Mitrofanoff/Monti), bladder augmentation, incontinent ileovesicostomy (ileal chimney), cutaneous vesicostomy, bladder neck sling and/or repair, and bladder neck closure.

A bladder diverticulum is an “outpouching” of the bladder lining through the outer muscle layer. It is similar in concept to a hernia. These are most commonly seen in children at the site where the ureter (the tube that transports urine from the kidney down to the bladder) enters the bladder. Some children have a weakness of the muscle in the area where the ureter enters the bladder. As the bladder fills and especially as voiding (peeing) occurs, the lining of the bladder in this area may herniate out temporarily until the bladder is emptied. This will occur each time the bladder fills and empties. A diverticulum itself is rarely a problem that requires surgery. However, they are usually seen in children who have vesicoureteral reflux (VUR) on the same side. If a child has both VUR and a diverticulum on the same side, the VUR is less likely to resolve. Additionally, the presence of a diverticulum makes the minimally invasive treatment option for VUR less effective. We have extensive experience with bladder diverticuli and can explain the issues involved and help determine the best treatment for your child.