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Pediatric Surgery (Pg 68-81) - page 18 / 33

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Anatomy:

Empty: behind pubic symphasis

Full: palpable suprapubically

Detrusor muscle: has no distinct layers

Trigone: 2 layers: one fuses with ureteral musculature, one is like detrusor.

Entire bladder is covered with pelvic fascia

Superior bladder covered with peritoneum.

Puboprostatic ligaments/ pubovesicular ligaments attach bladder to posterior aspect of pelvic bone

Umbilical ligament attaches bladder to anterior abdominal wall

Blood supply to bladder: superior, middle, inferior vesical arteries (from hypogastric), in females also from vaginal and uterine arteries

Bladder drained by many veins all going to hypogastric veins

Bladder lymphatics go to external iliac, hypogastric, common iliac, and sacral lymph nodes

Evaluations for anatomy:

Cystoscope: visualize

Retrograde pylography= inject radiocontrast into ureter to evaluate shape, size, position of ureter and renal pelvis

Urodynamic Evaluation:

Urodynamics: evaluates reservoir and micturation

Post void residual (PVR): amount of urine in bladder post void, can measure by catheterization or by ultrasound.  If increased residual than obstruction, cystocele, neurogenic bladder.

Cystometrogram (CMG): Measures bladder pressures, sensation, capacity and compliance.  Detects premature detrusor contractions. Normal should fill to 350- 500 mls without detrusor contraction, first sensations of void need btwn 150-250 ml, definite urge at 350-450.

Urinary flow rate (uroflow)- measures flow rate from urethra, normally men have peak of 20-25 ml/sec, women 20-30 ml/sec.  Low flow= obstruction, poor detrusor fitness.

Urethral pressure profile= not a common test, intraluminal pressure in urethra

Sphincter electromyography (EMG): evaluates sphincter activity, should increase with filling, and decrease with voiding.

Fluoroscopic cystography: visualize bladder neck and sphincter, can detect cystocele, bladder prolapse, reflux.

Congenital anomalies

Vesicoureteral reflux: (VUR)

Primary reflux: short intramural ureteral tunnel, due to lateral placement of ureteral bud from fetal bladder.  Reflux of dirty urine up ureter causes kidney damage.  Graded on degree: grade 1 and 2 will resolve as child matures, over 2 may require correction.

Secondary reflux: secondary to a surgical intervention, may require correction.

Cystitis may cause transient reflux.

Clinical evaluation:

VUR usually detected during UTI workup

29- 50% of kids evaluated for UTI have VUR.

Voiding Cystourethrogram (VCUG) is primary test for VUR: fill bladder with contrast and observe.

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