May 31, 2008


Introduction:Hypospadias is the congenital anomaly where the urethral opening is situated on the under surface of stomach instead of at the tip of the glance. In the fetal life there is aberration in the development of the urethral tube. Therefore, the development of the urethral tube is incomplete.

Types: The hypospadias may be distal & proximal or glanular, coronal, mid penile, proximal penile, penoscrotal & scrotal according to the site of urethral meatus.

Parts: Dorsal hood is formed by incomplete prepuce, chordee i.e.ventral curvature of penis, hypospadiac meatus, urethral plate. All or some components are present in any given case.

Investigations: The diagnosis is usually clinical. The more proximal hypospadias are evaluated to rule out intersex. In this context the descent of testes is important. If both the testis are fully descended then the possibility of intersex is less but if one or both testes are undescended then the possibility of intersex should thought of.

Management: The repair of hypospadias involves correction of chordee & formation of urethral tube. This can be done in one stage or in stages. There are many types of repair, Duckett's island prepucial flap, Byer's repair, Snodgrass (TIPS) repair are few of them.

May 6, 2008

Bladder calculus

Bladder stone is one of the common diseases children suffer from. The causes for this condition are many. The most important factor is infection. The stasis of infected urine gives rise to stone formation. The symptoms are dysuria, pain in lower abdomen, sometimes blood in urine, urinary retention etc. When one examines the child there will be slight tenderness in the suprapubic region i.e. lowermost central part of abdomen. This is because of bladder inflammation associated with bladder calculus.

Urine routine and microscopy shows pus cells indicating urinary tract infection. Plain X-ray abdomen shows bladder calculus in pelvic region if the calculus is radio opaque but if the calculus is radiolucent then X-ray will not show it. Ultrasonography of the pelvic region picks up these types of stones. It also shows the presence of cystitis & if there is any bladder outlet obstruction. Bladder outlet obstruction convincingly ruled out by doing micturating cystourethrogram (MCU). The dye is injected into the bladder by passing a small infant tube or bladder catheter. After injecting dye to fill up the bladder, the tube is taken out. The child is told to void and pictures are taken. If there is any bladder outlet obstruction like posterior urethral valves, it is immediately diagnosed. If it present, one has to deal with it along with removal of calculus.

Bladder calculus is removed by endoscopically (if the stone is soft and small) but majority of times it is removed surgically. The procedure is called as cystolithotomy. Through a small incision over the lower abdomen, the bladder is approached (after filling up with saline through bladder catheter), bladder is then opened, stone removed & bladder stitched back. The catheter is kept for 3-5 days after procedure.

Foreign body (FB) in stomach

Children in the age group of infancy to preschool age, has tendency to put anything in the mouth. In the older age group, the non-eatables are accidentally swallowed. The foreign body (FB) can be of two main types, sharp & blunt. Sharp FBs are commonly pins of any types & blunt FB are commonly coins.

The child usually has history of accidental ingestion of FB. The presentations ranges from asymptomatic i.e. no complaints to pin in abdomen, vomitings rarely distension of abdomen. The plain X-ray abdomen standing shows the radio opaque FB, the site, shape etc. If there are signs of perforation then gas under diaphragm. If the FB is blunt, seen in plain X-ray & child is not having any problem then laxatives & observation is recommended. The majority of times the FB passes in stool without any problem.

In case of sharp FB, one should not wait until symptoms appear. Further investigations like ultrasonography or CT scan is done. If the FB is in the stomach then it can be removed through the flexible gastroenteroscope while if it is the intestine then exploratory laparotomy to remove FB is recommended.

May 3, 2008

Sternocleidomastoid tumor of infancy

Sternocleidomastoid tumor of infancy is the most commonest neck mass found in perinatal period. The term 'tumor' is misnomer as the it is muscle fibrosis and not the tumor. The child usually present with a spindle shaped mass on the lateral aspect of the neck with restriction of neck movements (torticollis). The possible cause of Sternocleidomastoid tumor may be injury to the neck during delivery causing muscle injury and subsequent fibrosis.

It is commonly seen on right side, more in male children & in breech delivery. After clinical examination, ultrasonography is done to confirm the diagnosis. It arises from the middle or inferior portion of the lateral muscle of neck i.e. sternocleidomastoid muscle. The biopsy is not needed unless the USG shows different picture.

Treatment is conservative with physiotherapy of the neck. Passive movements of the neck allows mass to resolve by the age of six months. The indications for surgery are craniofacial asymmetry, persistent torticollis for more than one year and when physiotherapy fails.