Urinary Retention

The majority of newborns will void within the first 8 h of life, though some may void up to 24 h following birth (Mesrobian et al. 2004). If more than 24 h elapses, obstruction must be considered and investigated accordingly. Furthermore, a complete newborn physical ex-

Fig. 8.31. VCUG demonstrating posterior urethral valves in a newborn male with a known prenatal history of bilateral hy-droureteronephrosis and bladder wall thickening.

amination is important as even an apparently normal void does not rule out the presence of lower urinary tract obstruction due to the bladder's potential for compensation in the face of obstruction. The presence of a lower midline abdominal mass in a male infant is suspicious for posterior urethral valves (PUVs) despite normal micturition. If suspected, passage of a small feeding tube or Foley catheter will decompress the urinary tract and allow subsequent investigations to be carried out in a timely manner. PUVs occur in approximately 1 in 5,000 boys and are the most common cause of lower urinary tract obstruction in male infants (Mesrobian et al. 2004). Both US and VCUG are mandatory to visualize the upper tracts and definitively diagnose the presence of PUV (Fig. 8.31). Five signs of PUV on cystography are:

1. The presence of VUR

2. A thick-walled trabeculated bladder ± diverticula

3. Bladder neck hypertrophy

4. A dilated posterior urethra ± visualization of the PUV

5. Significant caliber change in the urethra distal to the PUV

Boys with stable renal function can usually undergo primary valve ablation in the 1st week of life. However, vesicostomy may be necessary to decompress and temporize the upper urinary tracts in those who cannot undergo cystoscopy such as preterm or small infants. Vesicostomy closure and valve ablation are then usually performed at 6-12 months of age following interval growth of the child. Overall, early prognosis is usually dependent on oligohydramnios and its consequent ramifications on pulmonary development in utero. Subsequently, the degree of renal impairment, secondary to dysplasia, will contribute to early postnatal morbidity and mortality.

Females may also present in the neonatal period with urinary retention and a palpable lower midline abdominal mass. Urogenital sinus anomalies, ectopic ureteroceles, and hydrometrocolpos may all lead to outlet obstruction and urinary tract dilatation. The diagnosis of a prolapsing ureterocele or imperforate hymen may not initially be obvious on physical examination. Both appear as cystic interlabial masses; however, careful inspection of the introitus will differentiate the two lesions (Fig. 8.32 a, b). Hydrometrocolpos due to an imperforate hymen results from the accumulation of uterine and vaginal secretions secondary to prenatal maternal estrogen stimulation (Hahn-Pederssen et al. 1984). Incision and drainage results in resolution of the vaginal, uterine, and urinary tract dilatation. Ectopic ureteroceles can also cause outlet obstruction in the newborn; however, they may also present later in childhood with a history of a protruding "bubble" or mass when voiding or recurrent UTIs (Fig. 8.33). Incision of the ureterocele will relieve the outlet obstruction and temporize the newborn while a complete evaluation of the upper urinary tracts is undertaken. Older children with an intermittently prolapsing ureterocele may be evaluated on a more elective basis with US, VCUG, and DMSA renal scan. The majority of girls with a uretero-cele will have a duplicated collecting system; definitive reconstruction will largely depend on the function of the renal moiety subtended by the ureterocele, although it should be directed at the prevention of UTI.

Occasionally urogenital sinus or anorectal anomalies will cause outlet obstruction and urinary retention in newborn females. The abnormal Mullerian duct structures penetrate the urogenital sinus and form a valve mechanism that leads to the prenatal accumulation of urine in the vagina and uterus. Newborns can present with a massively distended abdomen secondary to the urometrocolpos that causes both gastrointestinal and respiratory compromise (Fig. 8.34). It is important to thoroughly evaluate these infants, as congenital adrenal hyperplasia and a salt-wasting ne-phropathy can be associated with persistent urogenital sinus anomalies (Hamza et al. 2001). Careful inspection of the perineum will reveal a single orifice (in the case of a persistent cloaca) or two orifices when a urogenital sinus malformation is present. The treating physician

Fig. 8.32. a Interlabial mass in a newborn female subsequently found to be a prolapsing ectopic ureterocele. Note the hymenal remnant inferiorly which aids in the differentiation between Fig. 8.32b. b Interlabial mass in a different newborn female. This mass was secondary to an imperforate hymen. Hydrometrocolpos was drained following simple vertical incision of the hymen

Fig. 8.32. a Interlabial mass in a newborn female subsequently found to be a prolapsing ectopic ureterocele. Note the hymenal remnant inferiorly which aids in the differentiation between Fig. 8.32b. b Interlabial mass in a different newborn female. This mass was secondary to an imperforate hymen. Hydrometrocolpos was drained following simple vertical incision of the hymen

Where Hymen Female With Photos
Fig. 8.33. Photograph of an intermittently prolapsing ectopic ureterocele in a 6-year-old female with a history of "passing a bubble" while micturating

must be willing to undertake prompt decompression and diversion of both urine and feces (depending on the underlying anomaly) to allow interval growth and elective planning of the reconstructive surgery. Girls with isolated urogenital sinus anomalies and urinary retention may be managed initially by intermittent catheterization of the urogenital sinus followed by total urogenital mobilization (TUM) around 1 year of age (Gosalbez et al. 2005). Anorectal and cloacal anomalies are best treated by the cloacal disassembly technique advocated by Pena utilizing a posterior-sagittal approach for anorectal, vaginal, and urethral reconstruction (Pena et al. 2004).

Cloacal Anomalies
Fig. 8.34. Urogenital sinogram in a newborn female with an isolated urogenital sinus anomaly and massive abdominal distension. The patient was subsequently found to have severe ur-ometrocolpos requiring acute decompression
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Responses

  • otto
    Where is hymen in female with photos?
    7 years ago
  • adaldrida
    What are hymenal remnants,?
    2 years ago
  • sarah tewolde
    How to panitrate hymen?
    2 years ago
  • belle gibson
    What does the vaginal hymen look like?
    2 years ago
  • carmen wilson
    How those a girl hymen looks like?
    2 years ago
  • MARTYNA
    Where is hymen located in the virgina.?
    2 years ago

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