Paediatric Urology

Full Text Guidelines Summary of Changes Scientific Publications & Appendices Pocket Guidelines Archive Panel

2019

For the 2019 Paediatric Urology Guidelines, six chapters of the Guidelines have been updated through a structured assessment of the literature and these additional references and text updates have been incorporated.

Key changes in the 2019 publication:

  • Section 3.5 – Hypospadias: Both the literature and the text have been updated;
  • Section 3.7 – Varicocele in children and adolescents: The summary of evidence table and the level of evidence in a recommendation have been updated following the outcome of a systematic review by the Panel;
  • Section 3.13 – Vesicoureteric reflux: Both the literature and text have been updated;
  • Section 3.14 – Urinary stone disease: The literature has been updated resulting in minor amendments to the text;
  • Section 3.16 – Disorders of sex development: The text has been revised extensively;
  • Section 3.17 – Posterior urethral valves: Both the literature and the text have been updated.

 

1.5.1      New and changed recommendations

 

               3.16.6        Recommendations for the management of disorders of sex development

 

Recommendations Strength rating
Newborns with DSD conditions warrant a multidisciplinary team approach. Strong

 

Refer children to experienced centres where neonatology, paediatric endocrinology, paediatric urology, child psychology and transition to adult care are guaranteed. Strong

 

Do not delay diagnosis and treatment of any neonate presenting with ambiguous genitalia since salt-loss in a 46XX CAH girl can be fatal. Strong

 

 

 

2018

For the 2018 edition of the EAU Paediatric Urology Guidelines, the Guidelines Office have transitioned to a modified GRADE methodology. For each recommendation within the guidelines there is an accompanying online strength rating form which addresses a number of key elements namely:

  1. the overall quality of the evidence which exists for the recommendation;
  2. the magnitude of the effect (individual or combined effects);
  3. the certainty of the results (precision, consistency, heterogeneity and other statistical or study related factors);
  4. the balance between desirable and undesirable outcomes;
  5. the impact of patient values and preferences on the intervention;
  6. the certainty of those patient values and preferences.

These key elements are the basis which panels use to define the strength rating of each recommendation. The strength of each recommendation is determined by the balance between desirable and undesirable consequences of alternative management strategies, the quality of the evidence, and nature and variability of patient values and preferences. The strength of each recommendation is represented by the words ‘strong’ or ‘weak’.

In addition, four chapters of the Guidelines have been updated through a structured assessment of the literature and these aadditional references and text updates have been incorporated.

Key changes in the 2018 publication:

  • Section 3.9 – Day-time lower urinary tract conditions: Both the literature and the text have been revised extensively;
  • Section 3.10 – Monosymptomatic enuresis – bedwetting: the literature and the text have been revised
  • extensively;
  • Section 3.11 – Management of neurogenic bladder: Both the literature and the text have been revised
  • extensively;
  • Section 3.15 – Obstructive pathology of renal duplication: ureterocele and ectopic ureter: The literature has been updated resulting in minor amendments to the text.

1.5.1      New and changed recommendations

               3.9.5        Recommendations for the management of day-time urinary tract conditions

 

Recommendations LE Strength rating
Use two day voiding diaries and/or structured questionnaires for objective evaluation of symptoms, voiding drinking habits and response to treatment. 2 Strong

 

Use a stepwise approach, starting with the least invasive treatment in managing day-time lower urinary tract dysfunction (LUTD) in children. 4 Weak

 

Initially offer urotherapy involving bladder rehabilitation and bowel management. 2 Weak
If bladder bowel dysfunction is present, treat bowel dysfunction first, before treating the lower urinary tract condition. 2 Weak

 

Use pharmacotherapy (mainly antispasmodics and anticholinergics) as second line therapy in OAB. 1 Strong

 

Use antibiotic prophylaxis if there are recurrent infections. 2 Weak
Re-evaluate in case of treatment failure; this may consist of (video) urodynamics magnetic resonance imaging of lumbosacral spine and other diagnostic modalities, guiding off-label treatment which should only be offered in highly experienced centres. 3 Weak

 

 

               3.10.5      Recommendations for the management of monosymptomatic nocturnal enuresis – bedwetting

 

Recommendations LE Strength rating
Do not treat children less than five years of age in whom spontaneous cure is likely, but inform the family about the involuntary nature, the high incidence of spontaneous resolution and the fact that punishment will not help to improve the condition. 2 Strong
Use voiding diaries or questionnaires to exclude day-time symptoms. 2 Strong
Perform a urine test to exclude the presence of infection or potential causes such as diabetes insipidus. 2 Strong
Offer supportive measures in conjunction with other treatment modalities, of which pharmacological and alarm treatment are the two most important. 1 Strong

 

Offer desmopressin in proven night-time polyuria. 1 Strong
Offer alarm treatment in motivated and compliant families. 1 Strong

 

               3.11.6      Recommendations for the management of neurogenic bladder

 

Recommendations

 

LE Strength rating
Urodynamic studies should be performed in every patient with spina bifida as well as in every child with high suspicion of a neurogenic bladder to estimate the risk for the upper urinary tract and to evaluate the function of the detrusor and the sphincter. 2 Strong

 

In all newborns, intermittent catheterisation (IC) should be started soon after birth. In those with a clear underactive sphincter and no overactivity starting IC may be delayed. If IC is delayed, closely monitor babies for urinary tract infections, upper tract changes (US) and lower tract (UD). 3 Strong
Start early anticholinergic medication in the new-borns with suspicion of an overactive detrusor. 2 Strong
The use of suburothelial or intradetrusoral injection of onabotulinum toxin A is an alternative and a less invasive option in children who are refractory to anticholinergics in contrast to bladder augmentation. 2 Strong
Treatment of faecal incontinence is important to gain continence and independence. Treatment should be started with mild laxatives, rectal suppositories as well as digital. If not sufficient transanal irrigation is recommended, if not practicable or feasible, a Malone antegrade colonic enema (MACE)/Antegrade continence enema (ACE) stoma should be discussed. 3 Strong
Ileal or colonic bladder augmentation is recommended in patients with therapy-resistant overactivity of the detrusor, small capacity and poor compliance, which may cause upper tract damage and incontinence. The risk of surgical and non-surgical complications and consequences outweigh the risk for permanent damage of the upper urinary tract +/- incontinence due to the detrusor. 2 Strong
In patients with a neurogenic bladder and a weak sphincter, a bladder outlet procedure should be offered. It should be done in most patients together with a bladder augmentation. 3 Weak
Creation of a continent cutaneous catheterisable channel should be offered to patients who have difficulties in performing a IC through the urethra. 3 Weak
A life-long follow-up of renal and reservoir function should be available and offered to every patient. Addressing sexuality and fertility starting before/during puberty should be offered. 3 Weak
Urinary tract infections are common in children with neurogenic bladders, however, only symptomatic UTIs should be treated. 3 Weak

 

               3.15.5      Recommendations for the management of obstructive pathology of renal duplication±

                              ureterocele and ectopic ureter

 

Recommendations LE Strength rating
Ureterocele Diagnosis Use ultrasound (US), radionuclide studies

(mercaptoacetyltriglycine (MAG3)/dimercaptosuccinic acid (DMSA)), voiding cystourethrography (VCUG), magnetic resonance urography, high-resolution magnetic resonance imaging (MRI), and cystoscopy to assess function, to detect reflux and rule out ipsilateral compression of the lower pole and

urethral obstruction.

3 Weak

 

Treatment Select treatment based on symptoms,

function and reflux as well on surgical and

parenteral choices: observation, endoscopic decompression, ureteral re-implantation, partial ephroureterectomy, complete primary reconstruction.

3 Weak

 

Offer, early endoscopic decompression to

patients with an obstructing ureterocele.

Ectopic ureter Diagnosis Use US, DMSA scan, VCUG or MRI for a

definitive diagnosis.

3 Weak

 

Treatment In non-functioning moieties with recurrent

infections, heminephro-ureterectomy is a

definitive solution. Ureteral reconstruction

(ureteral re- implantation/

ureteroureterostomy/ureteropyelostomy and upper-pole ureterectomy) are other therapeutic options, especially in cases in which the upper pole has function worth preserving.

3 Weak

 

2017

All chapters of the 2017 Paediatric Urology Guidelines have been updated, based on the 2016 version of the guideline. Conclusions and recommendations have been rephrased and added to, throughout the current document. 

Key changes in the 2017 print:

  • Section 3.4 – Acute scrotum in children: The literature has been updated resulting in minor revisions to the text;
  • Section 3.5 – Hypospadias: Both the literature and the text have been revised extensively;
  • Section 3.6 – Congenital penile curvature: Both the literature and the text have been revised extensively;
  • 3.12 – Dilatation of the upper urinary tract (UUT) (UPJ and UVJ obstruction). A new section presenting the results of a systematic review interrogating the role of antibiotic prophylaxis in antenatal hydronephrosis has been included [4];
  • Section 3.14 – Urinary stone disease: Both the literature and the text have been revised extensively.

 

1.5.1      New and changed recommendations

 

3.6.4      Summary of evidence and recommendations for the management of congenital penile curvature

 

Summary of evidence LE
Isolated congenital penile curvature is relatively uncommon. 2a
Congenital penile curvature is often associated with hypospadias. 2a
Diagnosis is usually made late in childhood. 2a
The penis only appears abnormal when erect. 1b
Congenital penile curvature can cause aesthetic as well as functional sexual problems. 1b
Congenital penile curvature is treated with surgery. 1b
The goal of surgery is to achieve corpora of similar size. 1b

 

Recommendations LE GR
Ensure that a thorough medical history is taken and a full clinical examination done to

rule out associated anomalies in boys presenting with congenital curvature.

1a A

 

Provide photo documentation of the erect penis from different angles as a prerequisite

in the pre-operative evaluation.

1b A

 

Perform surgery after weighing aesthetic as well as functional implications of the

curvature.

2b B

 

At the beginning as well as at the end of surgery perform artificial erection tests. 2a A

 

3.5.6      Summary of evidence and recommendations for the management of hypospadias

 

Summary of evidence LE
Androgen stimulation therapy results in increased penile length and glans circumference. 1b
The complication rate is about 10% in distal and 25% in proximal hypospadias one-stage repairs. Higher and variable rate (between 28 and 68%) can occur in two-stage repairs. 3

 

 

Recommendations GR
In children diagnosed with proximal hypospadias and a small appearing penis, reduced glans circumference or reduced urethral plate, pre-operative hormonal androgen stimulation treatment is an option and the body of evidence to accentuate its harms and benefits is inadequate. B

 

Ensure long-term follow-up to detect urethral stricture, voiding dysfunctions and recurrent penile curvature. A

 

Use validated objective scoring systems to assist in evaluating the functional and cosmetic outcome. A

 

3.12.5   Summary of evidence and recommendations for the management of ureteropelvic junction (UPJ)-,

               UVJ-obstruction

 

Summary of evidence LE
In children diagnosed with antenatal hydronephrosis, a systematic review could not establish

any benefits or harms related to continuous antibiotic prophylaxis.

1b

 

In children diagnosed with antenatal hydronephrosis, non-circumcised infants (LE: 1a), children diagnosed with high-grade hydronephrosis (LE: 2) and hydroureteronephrosis (LE: 1b) were shown to be at higher risk of developing UTI. 2

 

 

Recommendation LE GR
Offer continuous antibiotic prophylaxis to the subgroup of children with antenatal hydronephrosis who are at high risk of developing urinary tract infection (uncircumcised infants (LE: 1a), children diagnosed with hydroureteronephrosis (LE: 1b) and high-grade hydronephrosis (LE: 2). 2 A

 

2016

All chapters of the 2016 Paediatric Urology Guidelines have been updated, based on the 2015 version of the guideline.
Conclusions and recommendations have been rephrased and added to, throughout the current document. 

Key changes in the 2016 print:

Changes in recommendations

  • Section 3.2 – Undescended testes (former Cryptorchidism chapter): complete update (prior to print publication)
    Two new figures have been inserted: Figure 1: Classification of undescended testes and Figure 2:
    Treatment of unilateral non-palpable undescended testes
  • Section 3.4 – Acute scrotum in children: The literature has been updated and minor text revisions made
  • Section 3.5 – Hypospadias: The literature has been updated extensively
  • Section 3.7 – Varicocele in children and adolescents: The literature has been updated extensively
  • Section 3.11 – Vesicoureteric reflux literature has been updated
  • Section 3.12 – Urinary stone disease literature has been updated

1.5.1 New and changed recommendations 

3.2.7 Recommendation for the management of undescended testes

Recommendation LE GR
In case of bilateral undescended testes, endocrine treatment is recommended. 4 C 

Section 3.6.5 Congenital penile curvature

Recommendation LE GR
Diagnose congenital penile curvature during hypospadias or epispadias repair using an artificial erection. 4 B
Perform surgery to treat congenital penile curvature. 4 B

3.7.5 Summary of evidence and recommendations for the management of varicocele 

Recommendations LE GR
Examine varicocele in the standing position and classify into three grades. 4 A
Use scrotal US to detect venous reflux without Valsalva manoeuvre in the supine and upright position and to discriminate testicular hypoplasia.    
In pre-pubertal boys and in isolated right varicocele perform standard renal US to exclude a retroperitoneal mass.    

US = ultrasound. 

3.9.5 Recommendation for the management of day-time lower urinary tract conditions 

Recommendation LE GR
If present, treat BBD bowel dysfunction first, before treating the LUT condition. 2 B

BBD = Bladder Bowel Dysfunction; LUT = lower urinary tract. 

3.11.6 Recommendations for the management of neurogenic bladder 

Recommendations LE GR
In all babies, start intermittent catheterisation soon after birth, except for babies without any clear sign of outlet obstruction. If intermittent catheterisation is delayed, closely monitor babies for urinary tract infections and upper tract changes. 2  B
Use anticholinergic drugs as initial treatment in children with overactive bladders.Clinical improvement is common but usually insufficient. 2 B
Use injection of botulinum toxin into the detrusor muscle as an alternative in children who are refractory to anticholinergics. 2  B
Use a bladder augmentation procedure, using a segment of intestine, in case of therapy-resistant overactivity of the detrusor, or small capacity and poor compliance causing upper tract damage and incontinence. 2  B
Use augmentation with additional bladder outlet procedures when both the bladder and outlet are deficient. Simple augmentation will suffice in most low-capacity, high-pressure bladders. 3  B
Augment with an additional continent stoma after bladder outlet surgery and in patients with urethral catheterisation limitations. 3  B
Follow-up of neurogenic bladder patients will be life-long.Follow-up includes monitoring of renal and bladder function as well as ensuring that sexuality and fertility issues receive particular care as the child gets older and moves into adulthood. 3 B

3.14.5 Recommendations for the management of urinary stones 

Recommendations LE GR
Perform a metabolic and anatomical evaluation in any child with urinary stone disease. 2a B
Any kind of interventional treatment should be supported with medical treatment for the underlying metabolic abnormality, if detected. 2a  B

Included summary of evidence sections: 

  • Section 3.2.7 – A summary of evidence has been added to Chapter 3.2 – Undescended testes.
  • Section 3.3.4 – A summary of evidence has been added to Chapter 3.3 – Hydrocele.
  • Section 3.4.4 – A summary of evidence has been added to Chapter 3.4 – Acute scrotum.
  • Section 3.6.4 – A summary of evidence has been added to Chapter 3.6 – Congenital penile curvature.
  • Section 3.7.5 – A summary of evidence has been added to Section 3.7 – Varicocele in children and adolescents.
  • Section 3.9.5 – A summary of evidence has been added to Section 3.9 – Day-time lower urinary tract symptoms.
  • Section 3.10.5 – A summary of evidence has been added to Section 3.10 – Monosymptomatic enuresis.
  • Section 3.11.6 – A summary of evidence has been added to Section 3.11 – Neurogenic bladder.
  • Section 3.13.4 – A summary of evidence has been added to Section 3.13 – Vesicoureteric reflux in childhood.
  • Section 3.16.4 – A summary of evidence has been added to Section 3.16 – Disorders of sex development.
  • Section 3.17.7 – A summary of evidence has been added to Section 3.17 – Posterior urethral valves.

2015

For the 2015 Guidelines, the text has been significantly reduced so that only key information is included and re-formatted according to the EAU non-oncology template so that all Guidelines follow a similar format.

This 2015 publication includes a number of updated chapters and sections as detailed below:

  • 3A Phimosis: The literature has been updated
  • 3B Cryptorchidism: The literature has been updated, minor text revisions made and one new recommendation added
  • 3C Hydrocele: The literature has been updated
  • 3D Acute scrotum in children: The literature has been updated and minor text revisions made
  • 3E Hypospadias: The literature has been updated extensively
  • 3G Varicocele in children and adolescents: The literature has been updated extensively
  • 3H Urinary tract infections in children: The literature has been updated and minor revisions made to the text
  • 3I Daytime lower urinary tract conditions: The literature has been updated, text revised and a recommendation added
  • 3J Monosymptomatic enuresis: The literature has been updated, text revised and three recommendations added
  • 3L Dilatation of the upper urinary tract: The literature has been updated
  • 3O Obstructive pathology of renal duplication ureterocele and ectopic ureter: The literature has been updated
  • 3Q Posterior urethral valves: The literature has been updated, minor revisions made to the text and some updates made to the recommendations

2014

New literature has been included and a limited revision applied for chapters:

Chapter 2
Phimosis: The literature has been updated. The treatment recommendations were not changed).

Chapter 6
Hypospadias (the literature has been updated and minor revisions to the text were made resulting in one additional conclusion and recommendation).

Chapter 9
Urinary tract infections in children (the literature has been updated and a treatment flowchart was added. The treatment recommendations were not changed).

Chapter 16
Obstructive pathology of renal duplication: ureterocele and ectopic ureter (the literature has been updated. The treatment recommendations were not changed).

Chapter 18
Posterior ureteral valves (the literature has been updated resulting in a minor change to the recommendations [follow-up section]).

 

2013

New literature has been included and a limited revision applied for chapters:
•    Chapter 2 “Phimosis”
•    Chapter 4 “Hydrocele”
•    Chapter 5 “Acute scrotum in children”
•    Chapter 8 “Varicocele in children and adolescents”
•    Chapter 10 “Daytime lower urinary tract conditions”
•    Chapter 11 “Monosymptomatic enuresis”
•    Chapter 12 “Management of neurogenic bladder in children”
•    Chapter 13 “Dilatation of the upper urinary tract (ureteropelvic junction and ureterovesical junction obstruction)”
•    Chapter 14 “Vesicoureteral reflux in children”
•    Chapter 15 “Urinary stone disease”
•    Chapter 17 “Disorders of sex development”. Former chapter 9 -“micropenis” has been incorporated.
•    Chapter 20 “Post-operative fluid management in children”
•    Chapter 21 “Post-operative pain management in children”

A complete update was achieved for chapters:
•    Chapter 3: “Cryptorchidism”
•    Chapter 6: “Hypospadias”; the management algorithm has been updated.

New topic included in this 2013 print:
•    Chapter 19 “Paediatric urological trauma”

2012

This is the latest version of the Guidelines on Paediatric Urology. The printed guideline states an incorrect maximum dose of botulinum toxin in neurogenic bladder in children (Section 13.5.3.1 Botulinum toxin injections). The correct maximum dose of botulinum toxin in neurogenic bladder in children is 200 units.

Amended topics (new literature included and text revision)
  • Chapter 6 “Hypospadias”
  • Chapter 12 “Monosymptomatic enuresis”
  • Chapter 13 “Management of Neurogenic Bladder in Children”:
    • 13.5.3.1 Botulinum toxin injections
    • 13.5.11 Lifelong follow-up of neurogenic bladder patients<
  • Chapter 15 “Vesicoureteric Reflux”
  • Section 16.5.3 Ureterorenoscopy
  • Chapter 17 “Obstructive pathology of renal duplication: ureterocele and ectopic ureter”

New topics:

  • Chapter 10 “Urinary tract infections in children”
  • Chapter 20 “Post-operative fluid management in children”
  • Chapter 21 “Post-operative pain management in children”

2011

The following chapters have been replaced:

  • Chapter 3 (Cryptorchidism)
  • Chapter 14 (VUR)