INDICATIONS FOR EXCRETORY UROGRAPHY IN CHILDREN

Full text

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SPECIAL

ARTICLES

INDICATIONS

FOR

EXCRETORY

UROGRAPHY

IN CHILDREN

By John Askin, M.D., Thomas Reichelderfer, M.D., Julian Salik, M.D., and

Jules Merritt, M.D.

Department of Pediatrics and Harriet Lane Home, Johns Hopkins University, and Departments of

Pediatrics, Urology and Roentgenology, Sinai Hospital of Baltimore

Dr. Reichelderfer was a Post Doctoral Fellow, National Foundation for Infantile Paralysis.

ADDRESS: (J.A.) Sinai Hospital of Baltimore, Monument Street and Rutland Avenue, Baltimore 5, Maryland.

1033

P

EDIATRICIANS are generally aware of the

high incidence of congenital anomalies

of the genitourinary tract. They are also

aware that between 80 and 85% of

uro-pathy in children, and possibly in adults, is

due to these malformations and they

appre-ciate the prime importance of their early

recognition. However, they are not in total

agreement as to the clinical indications for

excretory urography.

In order to determine the practical

mdi-cations, the results of all excretory

uro-grams performed in children seen at the

Sinai Hospital of Baltimore and the Harriet

Lane Home of the Johns Hopkins Hospital

during the years 1953 to 1955 have been

analyzed.

PATIENT MATERIAL AND

PLAN OF STUDY

In all, 797 excretory urograms were made in

656 children and, when deemed necessary,

retrograde and cystoscopic examinations were

also undertaken. A small group of these

chib-dren was referred to the hospitals for

consulta-tion because of known urinary tract disease.

The largest number were admissions to the

general wards or were followed in the

out-patient departments of the two institutions,

and had signs or symptoms which suggested

possible pathology in the urinary tract.

Radiologic requests for urography and

pa-tients’ charts were scrutinized to determine the

reasons for requesting the urograms. It was

found that these children presented certain

signs and symptoms, which for the past 15

years have been generally regarded as possible

indications for the performance of this

pro-cedure. The site of the lesion and the final

diagnosis were taken from the patients’ records

and from the radiologic, cystoscopic and

op-erative reports. This information was then

coded and punched upon McBee Keysort cards

and tabulated. The analysis included 656

ehil-dren from birth to 14 years of age, 340 males

and 316 females. During the period from

Sep-tember 1, 1953, to August 31, 1955, 595

uro-grams were performed in 482 children at the

Harriet Lane Home, and 174 children had 202

urograms at the Sinai Hospital. Urokon#{174}

(sodium acetrizoate) and Hypaque#{174} (sodium

diatrizoate) were the contrast media used.

Cystoscopy was performed in 29% of the

chib-dren and retrograde pyebography in 20%.

Surgi-cal procedures were carried out in 18% of the

children. Aortography was performed only

three times.

During the performance of 797 excretory

urograms in the 656 children included in the

study, there were no serious reactions to the

contrast media. Excretory urography was found

to be a relatively safe procedure. Four

reac-tions occurred in the group of 482 children

from the Harriet Lane Home; two of these

patients had histories of allergy. One child had

no reactions after 1 1 excretory urograms over

a 4-year period. There were no fatalities in

this series.

RESULTS

Detailed data concerning the specific

in-dications for urography and the incidence

of abnormal urograms are presented in

Table I. The criteria in the present study

coincided to a considerable degree with

those enumerated by Campbell.’ Of these

pyuria, recurrent abdominal pain,

hema-tuna, megacobon and abdominal masses

(2)

. . *

Indwatwns

Total

Urograms

No. Abnormal

Per Cent

Abnormal

Total 656 191 8

Pyuria, first attack 119 6 1

Pyuria, subsequent attack 50 18 36

Hematuria (microscopic), first attack

)

Hematuria (microscopic), subsequent attackJ

Hematuria (gross), first attack )>

Hematuria (gross), subsequent attackJ

38

77

7

19

18

5

Disturbances of urination 15 31 5

Abdominal mass 4 30 71

Recurrent back pain 11 3 7

Recurrent abdominal pain:

As only indication 67 8 14

Associated with other indications 54 43

Anomaly of external genitalia 4 7 9

Congenital malformation elsewhere 40 14 35

Failure to gain weight or grow 56 8 14

Elevated nonprotein nitrogen in the blood 9 10 34

Unexplained fever 45 14 31

Proteinuria 67 17 5

Hypertension 7 6

Enuresis 49 7 14

Trauma 8 3 38

Megacolon 10 0

-Hydrocephalus 13 1 8

Other (edema, collagen disease, hepatosplenomegaly) 70 13 19

* In most cases there was only one indication, but in some there were two or more.

Pyuria

When pyuria was present, the incidence

of pathology in the urinary tract was

greater in the male than in the female

(

Table II). When males were examined

dur-ing the first attack of pyunia, they had 30%

abnormal urograms as compared to 17% in

females, a ratio of approximately 2: 1.

Fob-lowing two or more attacks of pyuria, the

males showed 46% abnormal urograms and

the females 33%. This increase in incidence

of abnormal urograms after multiple

at-tacks of pyuria coincides with past

experi-ences.

The following diagnoses were made

when urologic evaluation was undertaken

after the second attack of pyunia:

MALES:

Obstruction of the bladder neck;

uretero-pelvic obstruction with hydronephrosis on the

left side. Pyelocaliectasis.

Ureteropelvic obstruction with

hydronephro-sis on the right side.

Extrophy of the bladder with chronic

pyebonephritis and ureteral kink.

FEMALES:

Hydro-ureteronephrosis, bilateral.

Hydronephrosis, bilateral. Ureterovesicab stricture, right.

Submucosal cyst of the urethra.

Neurogenic bladder with bilateral

hydro-nephrosis.

Incompetent ureterovesical valve.

Double kidney and ureter on the left side.

Urethral fold with pyelonephritis.

Cystitis.

Hydronephrosis on the left side.

Pyebonephnitis.

Ureteropelvic obstruction.

Hydro-uretero-hydronephrosis.

Ureteropelvic and ureterovesical stricture,

vesical neck contracture.

Hydro-ureteronephrosis, vesicle neck

(3)

*1

TABLE II

PYURIA

Excretory I rograms Performed at Time of

First Attack

Age Total No. Per Cent

(yr) No. Abnormal Abnormal

Excretory Urograms Performed at Time of

Subsequent Attack

Age Total No. Per Cent (yr) No. Abnormal Abnormal

Males

0-1 11 18

1-2 3 0 00

3-5 13 5 18

6-14 17 6 33

Males

0-i - W - 00

1- 0 00

3-5 5 40

6-14 3 3 100

Total 44 13 30 Total 11 5 46

Females

0-1 9 ‘22

1-’2 1’2 ‘2 17

3-5 23 4 17

6-14 31 5 16

Females

0-1 ‘2 ‘2 100

i-’2 4 1 25

3-5 18 4 22

6-14 15 6 40

Total 75 13 17 Total 39 13 33

Scrutiny of the types of lesions

demon-strated, following second attacks of pyunia

in girls as well as boys, indicates these

le-sions might also have been found if

urog-raphy had been performed at the time of

the first attack of pyuria. The old adage

that “urologic examination is indicated in

the male after the first attack of pyuria and

111 the female only after several attacks,”

does not appear tenable.

The following case reports illustrate

pa-tients having pyuria who were studied

dur-ing the first attack and after the third

at-tack, respectively.

D.B., a white female, was admitted to

Har-net Lane Home at the age of 7 days with the

complaint of “doing poorly since birth.” The

family history was noncontributory. Pregnancy

and labor were normal. The infant nursed

poorly from birth and had a weak cry. Cyanosis

and a cardiac murmur were noted. The

diag-nosis on admission was congenital heart disease

with a ventricular septal defect. This was not

of sufficient severity to account for her poor

condition. Examination of the urine on

admis-sion showed 20 to 30 leukocytes per high

power field but was otherwise negative.

Leuko-cytes were present in several subsequent urine

specimens. Culture of the urine revealed a

paracolon bacillus. Excretory urography

dem-onstrated a normal left kidney and a very

tortu-ous left ureter (Fig. 1). There was no

excre-tion of dye from the right kidney even after

3 hours. The bladder was noted to contain

a circular defect which was considered to be a

ureterocele. Cystoscopy revealed a bulging

mass which presented from the right and

ob-Fic. 1. Ureterocebe occluding the left ureteral

(4)

FIG. 2. Ureterovesical strictures causing advanced

hydro-ureteronephrosis on the left side and

mini-nial dilatation on the right.

I -

-scured the vision of the ureteral orifice. This

ureterocebe was removed surgically with

ex-cellent results.

J.A.L., a 6-year-old white female, was

ad-mitted to Sinai Hospital with recurrent flank

pain, fever, nocturia and urinary frequency.

Pyuria was present; two previous attacks had

responded to antibiotic therapy. An excretory

urogram showed left hydronephrosis (Fig. 2).

Cystoscopy demonstrated congenital

uretero-vesical strictures, and retrograde pyelography

showed bilateral hydro-ureter with

hydroneph-rosis, minimal on the right and advanced on

the left. Surgical correction of the

ureterovesi-cal strictures was subsequently performed.

Recurrent Abdominal Pain

When abdominal pain alone was the

in-dication for urobogic evaluation, abnormal

urinary tracts were found to be present in

14% of the cases (Table I); abdominal pain

was the only indication in 67 patients.

There were 54 patients with abdominal

pain associated with one or more

indica-tions for urologic examination; abnormal

urograms were found in 43% of these

pa-tients. Excretory urogram was performed

after complete study, which included a

stool, and tuberculin testing. The

abdomi-nal pain, in this series, was usually

pen-umbilical but frequently was located

else-where in the abdomen. There were no

characteristic features of the abdominal

pain associated with unologic disease. At

times the pain was so well localized as to

suggest appendicitis, at times so vague as

to warrant seanch for psychologic causes.

The principal lesions found in this group

of 121 cases of recurrent abdominal pain

were: Unetenopelvic strictures, 8;

hydro-ureter, 6; hydronephnosis, 5; ureterovesical

strictures, 3; vesicle neck strictures, 3;

con-genital strictures of urethra, 2;

neuroblas-toma, 2; uneteral calculi, 1; hypoplastic

kid-ney, 1; bifid pelvis kidney, 1; renal cyst, 1.

This is at variance with the findings of

Apley2 who studied 100 children with

re-current abdominal pain and found minimal

organic disease. He states that in most

chil-dren an accurate diagnosis can be made

without the need for elaborate

examina-tions. The following is a representative

case:

CA. was admitted to Sinai Hospital at the

age of 7 years. The patient, a girl, was the

second of three children, all of whom were

considered normal and healthy. The past

his-tory was not remarkable except for frequent

upper respiratory infections. Growth and

de-velopment had been normal and at the age of

7 years her weight was 24.7 kg and height,

123.8 cm.

The present illness dated back to the age of

6 years when the patient began to complain of

vague abdominal pain. The discomfort was

never severe, never at night, and on one

oc-casion only was there associated vomiting.

This episode of pain with vomiting lasted only

a few hours. Abdominal and rectal

examina-tions, blood pressure determinations and

in-vestigation of the urine gave no clues as to the

basis of the pain. Psychologic factors on some

occasions were considered to account for the

complaints. Sibling rivalry and preparation for

school were the factors most frequently

en-countered. The tonsibs were frequently

in-flamed and thought to be the cause of the

trouble, but their removal did not bring relief

(5)

fur

-‘ - .

-.. ‘4

FIG. 3. Hydronephrosis, left kidney; ureterovesical

and ureteropelvic stricture on the left side.

TABLE III

SPECIAL ARTICLES

SUrograms were obtained in 7 children with acute glomerulonephritis. usually because the disease was atypical at the onset.

ther study was undertaken. An excretory

uro-gram revealed hvdronephrosis on the left

side (Fig. 3). Cvstoscopic examination showed

the left ureteral orifice to be pin-point in size.

A No. 4 ureteral catheter was passed with some

difficulty. Another obstruction was encountered

below the ureteropelvic junction and was

over-come. Retrograde pyebogram revealed dilated

renal pelvis and calyces on the left side.

Dilata-tion of the stricture was followed by cessation

of abdominal pain.

H ematuria

Table III lists lesions demonstrated

when hematuria was a presenting symptom.

Eighteen per cent of the children showed

abnormal urinary tracts when microscopic

hematuria was present; 25% when gross

hematuria was present. The congenital

le-sions were more frequent and of a more

serious nature in the group of children with

gross hematuria.

Hematuria is a prominent symptom when

trauma is used as an indication for

urog-raphy. A kidney with congenital

malforma-tions appears to be more susceptible to

trauma than does a normal organ; 38% of

excretory urograms performed for trauma

and hematuria were abnormal. A

congeni-tal defect was demonstrated in three of

ExcilETonY 1ROGH.MS INDICATED BY PRESENCE OF MICROSCOPIC OR Gitoss HEMATunIA-MALES AND FEMALES*

iIierocopic Gross

Total

-1e

No.

Abnormal

Per GenE .

Abnormal Lesion Total No. No. Abnormal Per Cent Abnormal . Lemon 0-I I-2 3-5

6 I I

5 4 7 22 1 0 1 5 O -14 23 Ilydronephrosis -Ureteropelvic (up.)

stric-ture, hydronephrosis Vesical and renal calculi

Vesical neck contracture

Ilydronephrosis Chronic pyelonephritis.

Up. stricture with by-dronephrosis

Ureteral calculus, hydro-ureteronephrosis. 8 4 43 0 7 10 -5 9 3

Up. stricture. Cystitis. Chronic pyelonephritis

Ulcerative cystitis, double col-lecting system, chronic pye-lonephritis. Bilat. reduplica-cation of ureters. Right double collecting system Up. stricture with

hydro-nephrosis Bilateral up. stricture vesical neck obstruction Chronic pyelonephritis Up. ,tricture with

hydro-nephrosis

U.v. stricture witl Itydro-nephrosis, cystitis and trig-onitis

Right hydronephrosis

Acute glomerulonephritis with bifid ureters.

(6)

FIG. 4. Right hydronephrosis caused by a

post-caval ureter.

The patients presented below illustrate

the features associated with hematuria

when this finding is regarded as the

mdi-cation for excretory urography. Both

pa-tients had congenital lesions, one with, and

the other without, injury.

R.G., a 63-vear-old white male, was

ad-mitted to Harriet Lane Home because of gross

hematuria and hypertension following acute

otitis media. He had been treated with

anti-biotics for middle ear and upper respiratory

infections on many occasions in the past. It was

thought at the time of admission that he had

acute glomerulonephritis. The urine contained

albumin and mans’ erythrocytes and leukocytes.

A coliform bacillus was cultured from the

urine. The hypertension spontaneously

re-gressed. However, because of what seemed to

be excessive pvuria and the history of a

previ-ous brief attack of gross hematuria, an

ex-cretory urogram (Fig. 4) was done. An

obstruc-tion of the right ureter was observed. A post-caval ureter on the right was found at

opera-tion. This was corrected by plastic repair of

the renal pelvis and revision of the right ureter

with a satisfactory result. (This patient was

seen in 1951 and therefore is not in this series,

:‘

FIG. 5. Minimal hydronephrosis from a congenital

ureteropelvic stricture.

but details are recorded because of the rarity

of this abnormality and the early date at which

the lesion was detected.)

LW., an 1 1-year-old white male, fell, struck

the left flank and developed gross hematuria.

He was known to have rheumatic heart disease

and 2 years previously had the appendix

re-moved for acute appendicitis. An emergency

urogram done at the time of admission is

shown in Figure 5. A right congenital

uretero-pelvic stricture with minimal hvdronephrosis

was demonstrated. The same lesion was seen in

subsequent urograms. The boy was treated

conservatively.

Congenital Megacolon

There was no evidence of urinary

pa-thology in 10 cases of idiopathic megacolon

but this number is too small from which to

draw any conclusions. Swenson3 found 5%

of the cases of congenital megacolon he

studied to have evidence of megaloureter.

The experience of the authors coincides

with that of Williams at the Hospital for

Sick Children, Great Ormond Street,

Lon-don, who was unable to demonstrate any

pathology of the urinary tract in those

cases of megacolon in which an excretory

(7)

SPECIAL ARTICLES

Masses in the Abdomen

The most common cause of an abdominal

mass in children has been found to be of

urinary origin, i.e., hydronephrosis. Hence,

when an abdominal mass was the

indica-tion for excretory urogram, the finding of

urologic disease in 71% of the children in this

category is not surprising. The pathologic

conditions most frequently demonstrated in

this group of 42 cases were:

hydronephro-sis, 10; cystitis, 4; Wilm’s tumor, 4;

hydro-ureters, 3; duplication of ureter, 2;

con-genital stricture of the ureter, 2; strictures

of ureter at ureteropelvic junction, 2;

pyebo-nephritis, 2. Other interesting pathologic

diagnoses were renal infarction, horseshoe

kidney, congenital cystic disease of the

kid-ney and ectopic kidney.

DISCUSSION

The comparatively high incidence of

congenital anomalies of the genitourinary

tract has been frequently recorded in the

literature. Campbell,5 reporting on material

representing 47,483 necropsies performed

at Bellevue and St. Vincent’s Hospitals in

New York, and Mountainside Hospital in

Montclair, New Jersey, estimated that

con-genital malformations of the genitourinary

tract were present in 10% of the patients

necropsied. Helmholtz and Thompson6 in

1941 reported that 5% of necropsies

per-formed on newborns showed abnormalities

of the genitourinary tract. Lo Presti and

Waite,7 in a review of the necropsy findings

of 2,850 children performed at the

Chil-dren’s Hospital in Washington, D.C., found

irregularities of the urogenital tract in 154

or 5% of the cases. Askin and Rubin8

re-viewed the records of 1,300 children

ad-miffed to the Sinai Hospital of Baltimore

in 1949 and 1950 and found 3.5% of the

children to have proven anomalies of the

urogenital system. The above statistics are

based on hospital admissions and do not

represent figures for the total population.

The presence of a malformation of the

genitourinary tract is usually not easily

dis-cernable during childhood. McIntosh et

al.,9 for example, in a review of the

inci-dence of congenital deviations in 5,530

children followed for 1 year, found only

0.7% of all live births (41 cases) to have

mal-formations of the genitourinary tract; 38 of

this group had either hypospadias,

unde-scended testicle or hydrocele. In only three

infants was it possible to diagnose a

mal-formation of the urinary tract during the

first year of life. It is apparent that most of

the anomalies of the urinary tract were not

diagnosed by the ordinary methods of

ex-amination during the first year of

observa-tion. On the other hand, Sherwood et al.1#{176}

found 24 of 12,160 new-born infants to have

abnormal genitourinary tracts by careful

palpation of the abdomen in the neonatal

period. The presence of obscure urinary

malformations may become apparent only

as the growing child develops symptoms or

signs.

It is important that malformations of the

urinary tract be discovered as early as

pos-sible. To accomplish this, the clinician must

develop practical indications for excretory

urography. Visualization of the

genito-urinary tract is ordinarily required for the

investigation of pyuria, dysuria, enuresis,

albuminuria, obscure abdominal pain,

mal-formations of the external genitalia and

un-explained abdominal tumors.11 Additional

indications are: Failure to gain weight or

to grow, a congenital malformation

else-where, unexplained fever, hypertension,

elevated concentration of nonprotein

ni-trogen in the blood, trauma and recurrent

back pain. Less common indications in the

present series were: Collagen disease,

edema, hepatosplenomegaly, to

demon-strate a normal urinary tract prior to

ure-tero-subarachnoid anastomosis for

hydro-cephalus, and to discover megaboureter

as-sociated with megacobon. We are in

com-plete agreement with Thomasl2 who in

1642 wrote, “He trusted not the single

wit-ness of the water if better testimony he had;

for reasons drawn from the urine alone are

as brittle as the unnail.”

SUMMARY AND CONCLUSIONS

The indications for excretory urography

derived from the results of 797

(8)

Twenty-The most important indications for

per-forming this procedure were, in order of

frequency, pyuria, recurrent abdominal

pain, hematuria and abdominal masses.

The results of the study emphasize the

importance of urographic examination in

both male and female children after the

first attack of pyuria, and in children with

repeated attacks of unexplained abdominal

pain.

ACKNOWLEDGMENTS

The authors are grateful to Dr. Harry H.

Gordon, Dr. Robert E. Cooke and Dr.

Moses Gellman for their many helpful

sug-gestions.

REFERENCES

1. Campbell, M.: Urologic considerations in

pediatrics.

J.

Pediat., 38:387, 1951. 2. Apley,

J.:

Children with recurrent

abdomi-nal pain. International Congress of

Pedi-atnics VIII, Copenhagen, Denmark,

1956.

3. Swenson, 0., and Fisher,

J.

H.: The

rela-tion of megacolon and megaloureter.

5. Campbell, M. : Clinical Pediatric Urology.

Philadelphia, Saunders, 1951.

6. Helmholtz, H. F., and Thompson, G.

J.:

Urinary obstruction and infection among

children. Importance of their early

recog-nition. Proc. Staff Meet., Mayo Clin., 16: 6, 1941.

7. Lo Presti,

J.

M., and Waite, C. :

Genito-urinary tract anomalies. Scientific

Ex-hibit. American Academy of Pediatrics,

New York, Oct., 1949.

8. Askin,

J.,

and Rubin, S. : Survey of results

of combined pediatric and urological

clinic. Read at Annual Meeting of

Amen-can Urological Society, Old Point

Corn-fort, Va., 1948.

9. McIntosh, R., Merritt, K. K., Richards,

M. R., Samuels, M. H., and Bellows,

M. T.: The incidence of congenital

mal-formations: A study of 5,964

pregnan-cies. PEDIAmIc5, 14:505, 1955.

10. Sherwood, D. W., et al.: Abnormalities of

the genitourinary tract discovered by

palpation of the abdomen of the

new-born. PEDIAmIc5, 18:782, 1956.

11. Caffey,

J.:

Pediatric X-ray Diagnosis, 3rd

Ed. Chicago, Yr. Bk. Pub., 1956.

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1957;20;1033

Pediatrics

John Askin, Thomas Reichelderfer, Julian Salik and Jules Merritt

INDICATIONS FOR EXCRETORY UROGRAPHY IN CHILDREN

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