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 thehigh 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
. . *
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 examineddur-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
*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
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
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.
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
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
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 recurrentabdomi-nal pain. International Congress of
Pedi-atnics VIII, Copenhagen, Denmark,
1956.
3. Swenson, 0., and Fisher,
J.
H.: Therela-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 resultsof 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, 3rdEd. Chicago, Yr. Bk. Pub., 1956.
