Genitourinary Disorders Seen in Neonates: An Overview

Introduction

Neonatal genitourinary disorders are of different types varying from underdeveloped genital organs to large tumors present in the urinary system. The development of the genitourinary system includes both reproductive and urinary organs. Most genitourinary disorders are congenital or present at birth and could be due to genetic inheritance acquired through parent genes.

What Are the Common Genitourinary Disorders Seen in Neonates?

The genitourinary anomalies vary in males and females. Some of the commonly observed structural conditions are listed below.

In Males:

• Phimosis: This is seen as nearing the foreskin to the tip of the penis. The retraction of the foreskin becomes difficult. It is seen around six months of age. If the skin becomes too tight, interfering with hygiene or causing infection, then it is advised to do a circumcision of the penis.

• Paraphimosis: The forceful retraction of the tight outer skin of the penis can lead to physical injury. When the injury is severe, and the foreskin cannot be returned back, it is known as paraphimosis. It causes swelling and injury to the outer skin.

• Hypospadias: It is a condition associated with the location of the urethra. If the urethral opening or urethral meatus is present on the lower surface of the penis instead of a front opening, it is known to be hypospadias.

• Epispadias: If the urethral opening or urethral meatus is present above the penis instead of a front opening, it is known as epispadias.

• Exstrophy of the Bladder: The bladder is exposed or opens with the anterior or lower wall missing. The urine leaks from the bladder into the skin. The bladder is visible and is open below the abdomen. While urinating, the skin can become excoriated. Therefore a cloth covering is placed above the urethra without causing much harm to the urine flow. The infant is placed on the back or sideways positions without causing injury to the bladder. Such cases require immediate attention post-delivery, and surgical closure is conducted within two days.

• Cloacal Exstrophy: It is a condition with an open colon along with the bladder from below the abdomen.

• Hydrocele: This is caused due to excessive fluid accumulated in the testicles, making them swell.

• Cryptorchidism: It occurs when the testes fail to descend into the scrotum. It can cause a lingual hernia.

• Obstructive Uropathy: It is a condition where the kidneys start developing scarring or tumors in it. The kidney stone or tumor can cause partial or complete obstruction of urine flow. This causes the fluid to get accumulated in the kidney leading to its inflammation. This is known as hydronephrosis and can cause permanent damage to the kidney.

• Polycystic Kidney Disease: It is seen as a large fluid-filled cyst in the kidney. It is caused by inherited autosomal recessive traits. The kidney loses its ability to concentrate urine, leading to metabolic acidosis and high chances of urinary infection. The kidney makes bicarbonate which buffers the blood against high acidity.

In Females:

• Mullerian Hypoplasia: It is the absence of the proximal vagina, cervix, uterus, and fallopian tube.

What Are the Neonatal Genitourinary Disorders Affecting Both Males and Females?

• Urinary Tract Infection (UTI): It occurs both in males and females. In boys, it is more among the uncircumcised population. In females, it is seen in all age groups. Females have a short urethra, which makes them more prone to UTI infections. It is caused by E.coli bacteria and is caused due to contaminated feces. The symptoms usually shown are fever, chills, vomiting, and pain during urination. Children below the age of one are given antibiotic therapy. Other precautions taken are, avoiding holding the urine for too long, changing the undergarments, and avoiding the excessive use of chemicals like soap in the genital area.

What Are the Differences Observed in the Child Urinary System?

The child’s urogenital area shows the following features:

• Fluids have a larger portion of total body weight in children. Infants are more prone to FVO (fluid volume overload) or FVD (fluid volume deficit).

• Until the age of two, there is immature kidney function or low glomerular filtration rate (GFR).

• Newborn kidneys are immature but do function effectively. However, they are more prone to medication-induced toxicity, and the risk of kidney injuries is high.

How Are the First Episodes of Urination in Newborns?

Most newborns urinate within the first 24 hours of life. It is important to record and report the presence and absence of urination within the first period. If there is no urine output, it may be indicative of a urinary anomaly. Urine output varies by weight and age. Infants and toddlers show urine output from two to three mL/kg/hr. Preschoolers and young school-age children show one to two mL/kg/hr. School-age children and adolescents show 0.5 mL/kg/hr. The total urine output per hour is around 30 mL/kg/hr. The urine output (u/o) is roughly 50 mL at birth and around 700 mL in adulthood. The bladder has the capacity to hold around 50 mL of urine. These calculations are very important in understanding the health state of a child. Only a hydrated child can expel urine every two hours.

What Are the Differences Seen in the Child’s Genital Area at Birth?

• In Females: The genitals in preterm females may show swelling where the labia minora may protrude past the labia majora. Ovaries occur later than testes.

• In Males: In boys, the testicles may appear larger at birth. The testicles may fail to move into the scrotum or undescended testes or cryptorchidism. The foreskin might be tight at birth or phimosis. The sex organs do not mature until the child reaches puberty. The gender of the child is determined at the time of fertilization itself. The presence of the Y chromosome is essential for the development of testes and the associated hormones. Sex differentiation occurs early in the embryo.

The organs specific to the female or male child develop before the embryo has either male or female characteristics. By twelve weeks, the baby develops external genital features highly recognizable as male and female. However, some state laws have banned gender revelation in ultrasound, and the genital area is locked during scanning.

What Is the Relation Between Ear Problems and Genitourinary Disorders?

The kidneys, urinary tract, and ears develop inside the embryo at the same time. This causes a lot of combined dysfunction of the ear and the genital region at the same time. A low set ear location is highly predictive of urinary tract dysfunction. An imaginary line is drawn between the outer canthus of the eye and the upper tip of the ear pinna. If the ear falls below the line, then it is indicative of a urinary tract dysfunction. For example, nephrotic syndrome is seen as swelling in the eyes and ankles, which is caused due to high protein in the urine.

What Are Treatments Available to Manage Genitourinary Conditions in Males?

Children with obstructive uropathy are recommended for surgical procedures. Depending upon the location of the obstruction, various surgical procedures are done.

• Urostomy: It is a surgical procedure done to allow the easy flow of urine. A surgical opening or diversion is made around the abdomen called the stoma from the passage of urine.

• Colon Conduits: It is a urinary diversion procedure. The ureters are surgically cut and drained into a detached segment of the ileum of the small intestine. The end of the ileum is then brought into the abdominal wall. The urine is then collected into a bag attached outside the body. The bag is changed every three to five days.

• Nephrostomy: It is a catheter placed inside the kidney. It collects and drains the urine outside.

• Suprapubic Tube Placement: When access to the bladder is not achieved directly, then the suprapubic tube is inserted. It is also used in patients who require long-term catheterization where the internal catheter is not possible. It is also used during complex genitourinary surgical procedures and obstructive uropathy.

• Vesicostomy: It is done in conditions where the urine flows back to the kidneys preventing its outflow from the body. In this procedure, a small incision is made, and the bladder is sewn to the abdominal wall.

Conclusion

Genitourinary disorders in children are very common at birth. Most of them are resolved through surgeries. The major risk factors for genitourinary disorder in children are congenital or mutations of genes. It has a higher prevalence in certain ethnic groups. Certain developmental problems are highly associated with an imbalance in nutritional uptake by a pregnant mother, like a high intake of vitamin D is closely associated with birth defects in children.