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Pediatric Surgery (Pg 68-81) - page 20 / 33

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Interstitial cystitis

Etiology unknown,  Mainly in women

Lower abdominal pain, irritative voiding symptoms, microhematuria, negative cultures

May have mucosal ulcer (Hunner’s ulcer)

Dx of exclusion, pain and frequency may be debilitating

Histology shows chronic inflammation, mast cell infiltration, fibrosis

Treatment: bladder dilatation under general anesthesia, infusion of dimethyl sulfoxide, heparin, may need to remove bladder

Degenerative diseases

Bowel/bladder fistulae:

caused by sigmoid diverticulitis, neoplasm, crohn’s, or penetrating injury

Present with UTI, hematuria, pneumaturia, fecaluria

Eval w/ enema, cystogram, cystoscopy, CT

Treat: resect part of bowel, debride and close fistula

Vesiculovaginal fistula:

Caused by pressure necrosis during long labor or from surgical injury

Presents with continuous incontinence

Eval w/ cystogram, cystoscopy, IVP, or bilateral retrograde pyelography to look at upper tract

Treat with surgery, vaginal approach

Urinary incontinence

Stress: cough, sneeze, laugh, low resistance btwn bladder neck and urethra

Urge: can’t get there in time, involuntary contraction

Overflow: assc with obstruction, retention, uncontrolled emptying

Total: continuous, vesicovag fistula

Evaluation: history: meds, trauma, surgeries, deliveries, malignancy, diabetes, UTI, bowel habits, erectile and ejaculatory function

Physical exam include back, abdomen, pelvis, rectum, perianal sensation, tone, lower extremity neuro exam

Treat: if detrusor unstable (stress or urge): anticholinergics will relax

Surgery to restore anatomy for stress incontinence:   

Marshall-Marchetti-Krantz: anterior abdominal approach, dissect, tack higher

Stamey: vaginal incision, uses Dacron vascular graft to bolster

Raz: vaginal incision, sutures placed several times through urethropelic liagament

Transvaginal “sling” for stress incontinence, modifies bladder neck, uses, fascia or anterior vaginal wall to make a sling around urethra

For men there is an artificial sphincter like the one we saw in anatomy with a fluid filled reservoir and pump in the scrotum and a cuff around the urethra

Neurogenic bladder (there’s a nice chart in the book)

complicated, many CNS components

peripheral detrusor innervation: parasympathetics from S3, S4

trigone: sympathetics from T11-L2

external sphincter: S2 via pudendal

classifications:

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