Pitfall in Management of

Neonatal Urogenital Disorder

Bustanul Arifin Nawas

Division Pediatric Surgery
Hasan Sadikin Hospital
 Outline
• Definition of pitfall
• Neonatal Urogenital Disorders
• Pitfalls in Phimosis and Paraphimosis
• Pitfalls in Acute Scrotum
• Pitfalls in Bladder Exstrophy
• Pitfalls in Ureterocele
• Pitfalls in Hydronephrosis
Definition
Neonatal Urogenital Disorders

• Phimosis and Paraphimosis

• Acute Scrotum
• Bladder Exstrophy
• Ureterocele
• Hydronephrosis
 Phimosis and Paraphimosis

• Phimosis :
– Tightness of penile foreskin prevents retraction
of the foreskin over the glans (unretractable
prepuce)
– Physiological phimosis and pathological
phimosis

• Paraphimosis :
– The entrapment of prepuce behind the glans
penis
 Pitfalls
Uncircumcised penis

• To force retracting the foreskin in phimotic penis,

may cause tearing and edema of the foreskin

• Not to reduce the foreskin after penile examination,

cleaning of the preputium or catheter insertion 
paraphimosis
 Pitfalls
Circumcised penis :
• Inadequate bleeding control or underlying blood
dyscrasias  bleeding
• Inadequate compression in Plastibell circumcision 
bleeding
• Insufficient foreskin removed  trapped penis
• Entrapped inner preputium  inclusion cyst (smegma)
• Aggressive clamping or suturing on the ventral surface of
the glans  fistula urethrocutaneous
• Neonatal circumcision using electro cautery  necrosis
penis
 Neonatal Acute Scrotum
• Acute scrotal pain, swelling, and/or tenderness of intrascrotal
contents

• Cause of acute scrotum in neonates: spermatic cord torsion,

orchidoepididymitis, strangulated groin hernia.

• Neonatal testicular torsion: extravaginal, due to spermatic

cord twist.

• Orchidoepididymitis: inflammatory reaction due to infections

• Strangulated groin hernia: strangulated bowel protruded

through inguinal canal
 Pitfalls
• Neonatal testicular torsion
• Error or delay in diagnosis  undiagnosed spermatic cord
torsion
• Inadequate evaluation of testicular viability
• Inadequate contralateral testicular fixation  torsion

• Orchidoepididymitis
• Rare case in neonates  overdiagnosis

• Strangulated groin hernia

• Delay or error in diagnosis  necrosis of bowel and testis
 Ureterocele
• Congenital cystic dilation of the terminal, intravesical
portion or ectopic of the ureter
• May be totally or partially obstructed, resulting in
variability in size from small to very large
• Duplex system ureterocele occur in approximately
85 % of diagnosed cases. The upper renal moiety is
non functional and dysplatic (80 %)
• Management : conservative, endoscopic puncture
/incision, excision or marsupialization, heminephro-
ureterectomy
 Pitfalls
• Error in diagnosis prolapsing uroterocele or paraurethral
glands (Skene’s cyst).

Prolaps ureterocele Skene’s paraurethral glands

 Pitfalls

• Failure to identify duplex

system and ectopic ureter 
inappropiate diagnosis and
management

• Anti-reflux procedure is not

perfomed after excision of
ureterocele
 Bladder Exstrophy
• Midline defect and exists as part of a larger spectrum
of abdominal-pelvic fusion abnormalities
• Classic bladder exstrophy: the bladder is an open
plate on the lower abdomen and always includes
epispadias
• The aims of reconstructive surgery are to maintain
kidney function, to achieve urinary continence, and
to create or preserve functionally normal external
genitalia
 Pitfalls
• Using plastic clamp to cut umbilical cord  bladder
irritation or injury
• Manipulation of bladder mucosa during closure
• Bladder closure > 72 hours  reduce pelvic elasticity
 pelvic osteotomy needed
• Postoperative inadequate pelvic immobilization,
wound infection, urinary tube malfunction 
bladder dehiscence
 Hydronephrosis in Neonates

• Etiology: transient dilation of the collection system,

upper or lower urinary tract obstruction (PUJO,
VUJO, PUV), and nonobstructive processes (VUR).

• Pelvi-ureteric junction obstruction is the most

common caused of hydronephrosis detected
prenatally
 Pitfalls
• Error or delay in diagnosis because presentation of
hydronephrosis in infants usually asymptomatic,
except PUV
• Treatment in neonatal hydronephrosis is done after
4-6 weeks evaluation, unless in PUV
Thank You