Adolescent Urologic Problems

  Most urologic problems arise either early in life or late in life. Adolescence, in general, is usually a quiet time for urologists This article is a general overview of the most common abnormalities. Adolescent gynecology will not be reviewed.

Probably the most common urologic problem in male adolescents is a varicocele. A varicocele is the term used to describe varicose testicular veins in the scrotum. Veins, of course generally carry blood from one part of the body back toward the heart. The blood is propelled through the veins by skeletal muscle contraction, milking the blood through the veins. The blood is kept from "backing up" by one way "flap valves" throughout the vein. The testicular v are unusual in that they are relatively long veins with few valves. The right vein drains into the high flow low pressure vein, the vena cava. The left vein drains into a high flow high pressure vein, the left renal vein. This anatomy predisposes to the development of varicosities of the left testicular vein. That is why left varicoceles are much more common. If a right one exists without the presence of a left one, this should raise a red flag for evaluation of an abnormal occurrence such as a enal cell carcinoma with vena caval thrombus. The incidence of varicocele is approximately 9%. Decreased sperm counts occur in approximately 25% of patients. Decreased sperm motility occur in approximately 56% of patients. It is the most common treatable cause of male infertility. Infertility is thought to be caused by raising the temperature of the testicles causing damage to the sperm forming elements of the testes. This occurs in both testicles, but atrophy is most commonly seen in the affecte side. When surgical ligation is performed, improvement occurs in 50-70%. The average conception rate after ligation is 40-50%. Traditionally, the absolute indications for repair have included: a very large varicocele, one that causes pain, documented abnormal sperm count, or presence of testicular atrophy. More recently, many urologists have advocated ligation of varicocele during adolescence at the time of diagnosis in order to prevent testicular damage and future infertility. Both the risks of immediate surgical complications (primarily infection) verses the risks of future infertility must be discussed in order to make an informed decision and avoid future confusion.

Urinary Tract Infections (UTI) and Enuresis (Bed wetting) are unusual in adolescence and underlying anatomic abnormalities should be screened for with a voiding cystourethrogram and renal ultrasound or an intravenous pyelogram. The most common abnormal findings would be vesicoureteral reflux and ureteropelvic junction obstruction. For enuresis, occult neurologic disorders should also be considered. Vesicoureteral reflux exits when the submucosal portion of the dista eter is too short. Normally, the ureter drains into the bladder with the distal portion traveling between layers of the bladder wall. This effectively creates a "flap" valve so that as the bladder fills, the "submucosal" portion is pinched off preventing flow of the urine back up to the kidney. This is important because it prevents back pressure and retrograde movement of bacteria. The pressure combined with bacterial infection, causes permanent renal scarring and loss of function The treatment, n this age group, is almost always surgical re-implantation to create that protective flap valve. If preexisting damage is not too great, the outcome is usually very good.

There are several theories about the etiology of ureteropelvic junction obstruction. This abnormality occurs at the sight where the ureter originates at the renal pelvis. This origination or junction is too small to handle the outflow of the urine and progressive swelling of the renal pelvis occurs causing pressure damage and thinning to the kidney. Patients usually experience intermittent flank pain, especially with ingestion of diuretics (coffee or alcohol) or wit nsumption of large amounts of fluids. Treatment is surgical excision of the narrow area, then reattaching the ureter back to the renal pelvis. There are several less invasive procedures which may also be considered. One is the retrograde use of a cutting balloon which utilizes electro cautery to divide the narrow area. The other is percutaneous placement of a tube through the kidney which allows direct visualization of the area while cutting with a scope.

Renal Stones present with infection, pain or hematuria. They are treated exactly the same in children and adults. Either Lithotripsy or extraction is performed depending upon the size and location of the stone.

Underlying metabolic abnormalities such as hyperparathyroidism or dietary excesses should also be considered.

Testicular cancer is probably the least common, but the most feared of the adolescent urologic problems. History or presence of undescended testicle increases the risk of tumor fifteen times. Testicular cancer is the most common cancer in men ages 15 to 35. Presenting signs and symptoms are scrotal heaviness, pain or a testicular mass. The most common presentation is usually an asymptomatic testicular mass. Screening includes regular self examinations alo ith an annual exam by a physician. The two general categories of testicular cancer include nonseminoma and Non Seminoma. The initial treatment for both is a surgical procedure called an Orchiectomy (the removal of the testicle). Even in advanced stages, both types are highly curable. For advanced cases of nonseminoma, radiation and/or chemotherapy is utilized. For advanced cases of nonseminoma, surgery and chemotherapy is used. The surgery utilized is surgical removal of the lymph nodes from around the aorta and vena cava.

In summary, even though adolescence is usually an uneventful time for urologic abnormalities, the ones that do arise can greatly impact the future of the individuals' life. Careful genital exams in males are important to screen for varicoceles, undescended testicles, penile abnormalities, and testicular cancers. It is also important to consider congenital abnormalities in any male or female adolescent with incontinence, urinary tract infections, abdominal/flank pain maturia, or chronic illness.