Constantine Metreweli

Vesical and Urethral Problems

In introducing the subjet of vesical and urethral abnormalities it is essential first to mention a few points which can cause perplexity.

Full Circle: An Epilogue

Within the broad perspectives discussed in the Preface to this book the concept of revolution was introduced; that is the radical change in circumstances, attitudes and conditions which new methods of investigation have brought. Chapter 1 is concerned with the clinical context and here the concept of revolution is used in a different sense, the circular movement of thought around the specific clinical phenomena which lead to investigation. All this is rational and as it should be.

Renal, Abdominal and Pelvic Masses

When investigating mass lesions palpable in the abdomen of an adult it is common to think of studies of the gastrointestinal tract as a first step. However, if in children a similar approach is adopted then very often no definitive diagnosis is likely to be reached. Although mass lesions do arise in the abdomen in children they are relatively uncommon; they can range from teratomas of the stomach to pancreatic pseudocysts through to Crohn’s disease of the terminal ileum and so on. Much the commonest causes for a mass palpable in the abdomen of an infant or child are related to posterior abdominal wall structures generally and the kidneys and urinary tract in particular.

Urinary Infection and Vesico-Ureteral Reflux

Urinary infection is a complex subject and so it is fraught with controversy. Reflux of urine from the bladder provides a path by which bacteria may enter the kidney and cause pyelonephritis. Renal damage in the form of local scarring or renal growth failure may ensue. Investigatory protocols are needed to cover the requirements of current concepts of management of the individual child’s problem. Reflux from the bladder into the ureter may be a feature which runs in families and so the implications of this problem must be discussed. Not all urinary infection is symptomatic and screening of schoolgirls has shown a high incidence of covert bacteria; the relevance of this finding to infants and children in general is analysed.

Bone Changes in Chronic Renal Failure

Renal osteodystrophy may be defined as abnormal bone metabolism associated with renal disease. The basic defect is a failure to absorb calcium normally from the gut because of abnormal vitamin D metabolism. This may result in secondary hyperparathyroidism. The abnormal bone metabolism results in a disturbance of bone structure.

Obstruction in the Urinary Tract

Obstruction to urine flow may be complete or incomplete. Since rates of urine flow vary, more so in children than in infants, there may be no effective obstruction at low rates of urine flow, but incomplete obstruction prevents clearance of high volumes of urine.

Adrenal and Gonadal Lesions

Neither the adrenals nor the gonads are part of the kidney or urinary tract. And yet their relationships to each other and the kidney are close, both medically and in terms of investigations. Two lesions which affect the adrenal, neuroblastoma and phaeochromocytoma, are dealt with in other sections (Chapter 9 and Chapter 11 respectively). Neuroblastoma commonly presents as a mass lesion, which may be already very extensive at the time of diagnosis. Phaeochromocytoma primarily, but not invariably, manifests its presence in the clinical feature of hypertension. Neither phaeochromocytoma nor neuroblastoma have the adrenal gland as their only site of origin.

Acute Kidney Lesions

Like every other organ in the body the kidney has a blood supply which sutains the life of its cells. The structure of the kidney enables it to perform its cardinal role of excretion. When the blood supply to the kidney is reduced because of a reduction in blood flow and perfusion pressure, then function is compromised and the viabilitiy of the cells of the parenchyma endangered. Falling cardiac output and occlusion of the blood vessels of the kidney have, inevitably, serious and deleterious effects.

The Clinical Context

Incisive thinking about an individual infant or child’s problem demands clinical acumen. And this is an amalgam of clinical knowledge, experience and the capacity for experience. Astute clinical assessment provides the pointers for likely diagnoses. The objective of using imaging techniques is to confirm or refute diagnostic possibilities. As the investigatory process develops interactions between the findings from imaging and clinical assessments provide the synthesis of hard data on which rational management is based.

Innate Abnormalities of Renal Development

In their own ways innate abnormalities of renal development seem to present all the complexities of the coinage of the Common Market countries. But as J. K. Galbraith observed, “there is nothing about money that cannot be understood by the person of reasonable curiosity, diligence and intelligence”. And so it is with the innate problems of renal development.