My latest paper published in Paed Surg International.
I have proposed a new classification of Mega-rectum in ARM where I had observed 4 distinct sub-types over the last 25 years.
Also discussed strategies for prevention- 'Our incidence of megarectum dropped from 26% before 2013, to 4% thereafter, in keeping with several changes introduced by the senior author (DM).
As this photograph shows, it is possible to mobilise some testes through the scrotum itself thus avoiding any scar on the abdomen. Not many surgeons, even now, are comfortable doing this surgery ‘entirely’ from the scrotum.
See paper published by me on this subject - 'Management of the low undescended testes by scrotal fixation'. D.Misra, L.Kapila. Urol, 49:762-5, 1997.
How common are they?
About 4% of all boys are born with an undescended testes, however by the age of 1 year only 0.8% still have this problem.
Undescended testes do not form sperms well unless they are in the cold environs of the scrotum. There is also a 6-8 fold increase in development of malignancy later in life.
The recommended age for surgery is 18 months, the surgery itself takes 30-45 mins and children are sent home the same day.
What are retractile testes?
A lot of young boys simply have a retractile testis, where the testis sometimes gets pulled up because of muscular contraction. It is vital not to label these as undescended testes and subject them to an unnecessary surgery.
Upto 3% of boys and 1% of girls may get a Urinary tract infections (UTI) in childhood. After appropriate antibiotics, all children need to undergo an ultrasound of their urinary system.
The younger the child , the higher the chances that there will be an abnormality found, and therefore below the age of 1 year a DMSA scan and a cystogram are also needed.
Sadly, UTIs are often missed in the first few years of life and some children are only picked up later with scarred kidneys.
Conversely, if urine is improperly collected a false diagnosis of a UTI may be made and the child subjected to unnecessary investigations.
Nocturnal enuresis or bedwetting is not uncommon, typically 8% of 8 year olds and 5% of 10 year olds still suffer from this problem. Various forms of management involve use of alarm systems, waking them up in the middle of the night, use of star charts, and in selected cases some medications may be tried.
The success rate is variable, this can be a difficult condition to treat and sometimes all one can do is wait for the children to outgrow this problem.
Daytime urinary incontinence, on the other hand, is a different entity altogether. Children with this condition may simply have an immature bladder, but an early referral to a paediatric urologist is recommended for appropriate investigations.
Consultant Paediatric Urologist Surgeon
How common is it?
Surprisingly, all boys are born with a tight foreskin, however the foreskin starts opening up with age.
Some boys with a tight foreskin may develop balanitis (infection) at a later age. Rarely this may result in scarring with resultant difficulty in passing urine.
As long as the clinician can rule out BXO by clinical examination, it should be possible to treat some tight foreskins with steroid creams, the success rate is approximately 40-50%.
A circumcision surgery may be performed for religious or medical reasons. It may be done under local anesthesia, or under a light GA.
In this condition, the patient passes urine from a hole which is situated further down the penile shaft, rather than on the tip of the penis.
In the more severe cases, the penis may also be bent (chordee).
Hypospadias surgery can be technically very exacting, and complication rates can be high particularly in those centers which do few operations a year.
The surgery can be done in 1 or stages, anytime between the ages of 9 months to 2 years.
If a child already has had 1 or more failed repairs before, then pre-operative treatment with testosterone may be beneficial.
World Congress of Hypospadias, Philadelphia, Nov 2019
5 min video - We are proud of the fact that no fistula in the scrotal or perineal group, ever needed more than 2 attempts at closure ( literature records upto 5-8 attempts in this severely affected group).
Warning: Graphic Surgery Content
Mr Devesh Misra
An experienced, expert paediatric surgeon in London, UK. He has special interest in Newborn Babies (neonatal) & Children Surgery, GI surgery & Paediatric Urology.
An experienced pediatric surgeon London
Treatments for urology conditions, circumcision, tight foreskin, balanitis, undescended testes, hypospadia, constipation etc.