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W HILE IT MAY seem obvi- ous that adult urological concerns dif fer from those of children, it's an important distinction. Urologic issues among infants, children and teens often relate to development. In young patients, urologic consultations are commonly a result of congenital defects or developmen- tal concerns, which may resolve on their own or may require surgical correction. Here are common concerns that require evaluation by a pediatric urologist. Cryptorchidism Among infant boys, 1–2 percent experi- ence cryptorchidism, in which one or both of the child's testicles do not descend into the scrotum. The condition is more common among those born prematurely. The risk from undescended testicle(s) revolves around the increased risk of cancer and fertility issues, as well as the possibility of injury to the testicle(s) in some cases. In about 20 percent of cases, the testicles descend in the first six months after birth. Historically, the treatment approach had been to monitor for up to five years for natural descent, however the period of observation has been short- ened. Today, the accepted approach is to monitor the child until six months of age then surgically bring the testicle into the scrotum. Intra-abdominal testes can be approached laparoscopically. Hypospadias A b out f ive of 1,0 0 0 b oy s h ave hypospadias. This congenital condition relates to the position of the urethral opening in the penis. In hypospadias, the urethral opening is positioned somewhere along the shaft of the penis, but not at the tip. Most cases — around 80 percent — have a distal hypospadias. In addition to the abnormal place- ment of the opening, the foreskin can be affected. In many instances this results in the appearance of a "natural circumci- sion." In some instances, hypospadias is associated with curvature of the penis. Hypospadias is normally repaired around the age of six months. Further evaluation may be needed if hypospadias is associ- ated with cryptorchidism. Circumcision-Related Issues While circumcision rates across the United States are lower, rates in the Midwest remain high. The most recent American Academy of Pediatrics state- ment on circumcision is more supportive of the benefits than previous opinions. Anecdotally, in my experience between 80-90 percent of boys are circumcised. As a result, I've encountered families who move here from other parts of the country and then request circumcision. Of those who have been circumcised, problems related to the procedure can develop immediately or may present later. For example, patients may have excess foreskin present or develop adhe- sions, where the foreskin sticks to the glans. Correction of skin concerns may help prevent infection in some cases or may be purely cosmetic. Vesicoureteral Reflux (VUR) One of the biggest changes in pediat- ric urology over the last two decades is the approach to VUR. In the past, most children were treated surgically. While children still receive surgery to correct VUR, the condition is more often managed medically. The concern with VUR is that it can lead to kidney infections and scarring. If the child develops recurrent infections, then surgical correction is likely necessary. This decision is best made, however, on a case-by-case basis. Approximately 1 percent of children experience VUR. Inguinal Hernias Children at any age can develop a hernia that requires immediate attention. In the pediatric setting, the hernia often presents as a bulge in the groin area or, for boys, down into the scrotum. The bulge can come and go, and is often not painful. Hernias have a risk of becoming incarcer- ated if not corrected surgically. A variety of other congenital anomalies are treated by pediatric urologists. Major anomalies of the bladder or urethra may be encountered, often in association with anomalies of the rectum/colon. In these cases, a multidisciplinary approach involv- ing multiple services is utilized. Minimally invasive and laparoscopic approaches are increasingly used for urologic issues, especially kidney issues. Dr. Curtis Clark is a board-certified, fellow- ship-trained pediatric urologist. He is a member of the Akron Children's Hospital Pediatric Urology Department and provides services at Pediatric & Adolescent Urology, Inc. ■ Among Pediatric Patients by Curtis Clark, MD Common Urological Concerns +++++++++++++++++ + +++ + +++ +++++++++++++++++ PEDIATRICS 1 0 | Cleveland/Akron/Canton MD NEWS ■ M D N E W S . CO M ■ M A R C H /A P R I L 2 0 1 5