[Music] thank you for taking time from your busy day to watch this special presentation from the El Paso County Medical Society I'm Dr Joel Hendricks president of the El Paso County Medical Society and it is my hope that you will find our program of great interest educational and informative about the medical care provided by some of our best physicians in our country right here in the Borderland from all of us at the El Paso County Medical Society please enjoy tonight's [Music] program urinary tract infections they're a lot of fun right we are adults but if your child has a urinary tract infection how can you tell if they're not of the age where they can actually tell you what's happening are there body cues that they're telling you about are there body cues that you can watch for what are some of the other conditions that are associated with urinary tract infections and just in general the urinary tract we're here to talk about Pediatric Urology today and it's important for parents to understand their child's Anatomy yes we're going to talk about genitalia tonight I know that sometimes it's cringeworthy to do that but when your children are growing up they are often embarrassed as the parents to talk about these things so we'd like to bring a lot of that to the Forefront tonight so that you have an ability to talk to your kids or your grandkids or whoever might be growing up around you um and also signs for you to watch out for if there are issues what is normal and what is not normal as far as function and pain in the genitals this evening's program is underwritten by the El Paso children's hospital and a big thank you to the El Paso County Medical Society for bringing this program to you I'm Katherine Berg and this is the AL Pasa physician thanks again for joining us I'm kathern Berg with the El Paso physician and we are talking about Pediatric Urology tonight and uh we were just discussing that there are so many things in our culture in America and in Mexico that are kind of taboo to talk about and I think that today it's super important and we're going to start with babies brand new babies we're going to start maybe even with some conditions that we might be able to see prior to a baby being being born and this is all in the genitalia area so I would like to introduce uh Dr sh oh I didn't even ask you how to pronounce your first name sorry we're just sitting here caught up in conversation this entire time you're just Dr Alam but pronounce your first name shamile shamile Dr shamile Alam and he is a pediatric urologist at El Paso children's hospital and we have Belen tases who is a nurse practitioner at El Paso children's hospital and thank you so much for being here um what I'd like to do Dr Alam if you can sort of discuss what your background is what is a pediatric on oncologist a pediatric urologist um just so that people at home can kind of understand what it is that your specialty is and Blen I'm going to do the same thing with you in a few moments as well Dr Alam so pediatric eurology is basically as you said a field of medicine looking at the genitals the urinary tract that includes the kidneys the bladder the URS as well as the urethra and in boys testicles and girls ovaries as well as the uterus and Pediatric Urology is both a surgical and a medical specialty so it is unique amongst surgical Specialties in that probably half of Pediatric Urology is in fact medical management of the kidney and the urinary tract the other half Pediatric Urology is Surgical and we can talk about some of those conditions as we get further on today but the main conditions that we take care of are regarding the genal in the urinary tract okay thank you very much um I know that we you've been working with Blen here for a while and I know and Blen we want to uh talk about nurse practitioners in this realm and doctors in this realm but you do an awful lot when it comes to urinary issues with children in the nurse practitioner role what is it that your role is and how does it complement the doctor's role in this situation well the good thing about my role is that I'm in the clinic every day Monday through Friday because I don't go to the operating room that's not my area so if there's any problems there's any referrals anybody needs to be seen immediately or right away I'm there you have the first lines of Defense when people start coming in if there's questions I um they could text me they could call me you know whatever is helpful if you know they have recurrent UTI and they've already had six UTI or and they're like we I need this child to be seen you know I need help and we need to get to the bottom of it it's like we need to investigate why are we having so many U and are they true UTI so I I feel like that's my way of helping the Pediatric Urology Community by being more available and I'd like to speak this evening about parents and the questions that they ask I'm going to I'm going to direct a lot of those your way I'm going to ask you in a little while what are Mo some of the most common questions that parents ask you but then also seeing past that cloud right they're going to ask a question but you really know that they mean a b c and d because certain topics again it's not that it's taboo but sometimes they don't know how to ask an uncomfortable question or an embarrassing question that they may consider an embarrassing question so I'd like to uh turn it over to Dr Alam for a second and talk about some of the most common issues that you see and then we'll transfer it also to Blen and see what some of those questions are that the parents are asking about so in your day-to-day life what are some of the most common issues that you see the most common Pediatric Urology um referrals in males are usually about the foreskin questions about the foreskin and that's the first thing that you see with your baby boy is the forkin and parents have to make a decision if they want the child circumcised or if they want to wait and there are no real right answers uh in terms of that but as time goes on sometimes uncircumcised children may have some issues or more importantly there may be um some concerns when they're seen by maybe Physicians who are not used to children who are uncircumcised and so we get a lot of oh interesting okay we get a lot of uh evaluation for circumcision related problems that aren't always problems if you were to throw and it doesn't have to be exact but if you were going to throw a percentage out there of how many uh males are circumcised versus not circumcised is that a high percentage you know what in general 5050 60 6040 9010 it it really varies depending on where you are in the United States um I mean in Europe it's the majority are not circumcised in the United States it's it falls really under cultural lines okay so in you know the the east coast and some of the big cities probably greater than 50% of the males are circumcised okay when you get closer to more Hispanic communities the rate of circumcision tends to go down and then there are some outliers for example in inner cities where there are a lot of patients who are on public Insurance sometimes circumcisions aren't paid for and by default even though the parents may want their child circumcised they are not circumcised and so it's very difficult to come up with a number because not all children have problems who are either circumcised or uncircumcised but it tends to follow those lines and in general do B I'm going to ask you this question um so I'm trying to think because usually prior to a birth the parents will know am I going to have my young boy circumcised or not what are some of the questions that parents ask you about whether it's a cleanliness issue just just medical issues I understand the cultural issues around circumcision but just medical cleanliness Etc what are some of the questions that you receive from parents on should I should I not or is that even an issue yes no they do ask a lot and they want to know like is it medically necessary is it going to cause you UTI because they hear that a lot I want them circumcised because it's a hygiene issue and because it's going to prevent UTI and it's not true okay so on that note let's carry that a little further so um and I'm thinking again diapers are an immediate thing and let's say it's a brand new parent someone who hasn't changed diapers before and now they have a young boy who's not circumcised um and there are let's talk about loose stools right and so it's just a mess M how are questions presented to you of how to clean properly taking the fores skin back or not with with cleaning when your baby is like tiny tiny tiny and then going forward too and we can carry that through to when they're starting to party train and when the young men are starting to young men when the babies when the when the toddlers are starting to clean themselves Etc explain some of that that thought and Theory as you're talking to parents so the foreskin does need to be retracted it does not need to be forcefully retracted at all um smegma is a white cheesy like substance that forms naturally and that forms a barrier and helps the for skin separate by itself on its own okay so forcefully you don't want the skin to tear because this if the forkin tears and it bleeds and then they're hurting and that skin can Scar and cause further problems you know I was doing research on this topic today and there was a story specifically about that which is why I wanted to bring it up um and again the reason I'm saying this too is brand new parents have never dealt with it one way or the other the father in the story that I was reading was circumcised so it was kind of new to them mom didn't want the circumcision for the for the young man and so it it did talk about a major infection that occurred because Dad kept you know again forcefully moving things around so um going through the life in general um you're looking at young boys that are circumcised is there any difference in cleaning diaper cleaning and and the way I understand there really isn't but I want everybody to hear from Medical Professional there is no difference okay but you do have to consider one thing that if the dad is circumcised and the little boy is not as he's growing up and he's taking a shower with Dad or Dad's you know how come you look like this oh and I look that right so you have to take those kind of things into consideration right and that goes back to the opening of the of the statement right it's like when is it okay to speak about genitals and it's like in my opinion and you guys tell me from the get-go I mean never make it an issue it's like this is why and this is what it is and Dr Alam maybe describe some of the the situations you've been in and questions that you've been asked by parents well regarding circumcisions and foreskin it's usually those questions uh there's a great quote from one of our old old pediatric textbooks and it starts off by saying the only person who should manipulate the foreskin is its owner ah and so we have a tendency to pull the skin back to do a bunch of different things and it just kind of creates problems but in addition the diapers have gotten so good at absorbing fluid these days that sometimes children may sit in diapers longer than they would have in cloth diapers right maybe the children get a little bit dehydrated and sometimes that urine gets a little bit strong and that can irritate the skin right and then all of a sudden the foreskin is blamed as a problem I like to explain it this way to the families no matter if you believe in a God or Mother Nature or whatever you believe in what life force could create something where when you're born it has to be removed it doesn't really make sense and I don't get involved in terms of religious discussions or otherwise we tend to do what the families really want us to do but when they have questions we try and make them understand that there really no good right or wrong answers and that I love that you're really making that a point this evening as as well um so other than that what are some other Pediatric Urology type issues we can um I wouldn't mind going into some of the congenital stuff immediately because I think sometimes we run out of time and I think that's so important as pediatric urologists what are some of the congenital issues that that you see happening that you have to deal with so it's an important fact to note that with prenatal screening with ultrasounds the most commonly identified problem prenatally is in fact your logic whether it has to do with the most common is the most common interesting okay whether it has to do with dilation of the kidney uh problems with the position of the kidney problems with the amount of fluid around the baby as it relates to the kidney bladder or urethra or genal anomalies and so we tend to detect a lot of pediatric Urologic conditions prenatally so many patients when they're pregnant and go see their Maternal Fetal Medicine physician will have a some kind of Urologic anomaly and we counsel those patients prenatally in order to help them to a birth center and a birth plan it should also be noted that the majority of those conditions don't necessarily require surgery okay but early detection helps the fam's plan and demystifies that sort of shock that you would get after delivery that something's wrong with my child now when it comes to the penis one of the more common conditions that we see are abnormalities of the foreskin that are also associated with problems in the urethra meaning that the urethra doesn't make it all the way to the tip that's called hypospadius okay and that happens about 1 in 450 live births oh okay when I was in medical school it was 1 in 1400 and yes it hasn't increased with time that's interesting we don't really know there are some theories and we don't need to get into them but it is more common than it used to be so how that has to be surgery correct at in this point so you have to somehow extend we do um sometimes children can live with their hypospadius and part of the reason why it may be more common is that we are more interested in looking for it um I've seen some statistics that it's actually one in 150 okay when you include abnormalities of the foreskin and how dangerous it is it is it is it something that uh you can go on for years and not realize like you said you're now trained to look for it um in the past have that been has that been something that you will eventually find anyway or are there just problems from the get-go that go undiagnosed well usually it the conversation is around circumcision so the pediatrician will notice that the forkin is incomplete or abnormal and the rra isn't at the tip and that usually stops the circumcision process so the most important thing is when a child has a hypospadius that they don't have circumcision because we use some of that skin to reconstruct the penis okay now unfortunately with hypospadius the more severe the hypospadius mean the further it is away from the tip the more It's associated with curvature of the penis okay and curvature of the penis can cause some problems in the future both with erections as well as urination and those patients typically will benefit from surgery okay and when you say benefit from surgery if you don't mind uh and I love just doing ideas of case studies um again the story that I read today because I think people have a way of wrapping their head and arms and mind around a case study So when you say surgery what exactly physiologically are you doing in the operating room when you're trying to correct this condition so the simple explanation is at the end of the operation the child will look like he is circumcised okay but that's kind of a simplistic view what we do is we straighten the penis so we take away the curvature we and how do you do that again I'm just thinking physiological so is it a muscle situation is it so you've got the urethra that's that's the urer sorry urethra the Ure we were're talking about this before the show um so physiologically describe what it is that you're doing in surgery so the penis is curved right the urethra may be below where it should be correct so the first thing we do is we take an incision take the skin down and straighten the penis okay which sometimes actually drops the urethra that makes sense right and then we reconstruct the urethra by tubularized it all the way to the tip and what material do you use we usually use very very fine suture probably the thickness of your hair okay and we use operating microscopes and operating magnification to do so and then we you can't just make a tube you actually have to put some tissue with some good blood supply over it and then you put a small stent in to what's called divert the urine so the urine drips out of the stent and that stays in anywhere from 5 to seven sometimes 10 days while the urethra heals okay and then it's taken out in the office yeah it's a pretty straightforward procedure again the frequency of hypospadius really is leaning towards the more minor hypospadius but my actual interest is reoperative hypospadius because sometimes patients have surgeries that don't go to plan and I do a lot of secondary tertiary quary surgeries for that condition so I'm thinking too just in my head right you're doing a surgery you're reconstructing and this is a little tiny person and as this little tiny person grows to be a little bit of a bigger person a bigger person is what you're reconstructing is is again it's live tissue so I'm assuming what I'm hearing if I'm hearing it correctly that the live tissue just grows with the child is that correct is there been any issues regarding that there's been a lot of issues okay so um if the surgery is done in a certain fashion um the patients can develop scar tissue and as they get older the curvature doesn't go away oh yeah and a 15-year-old boy with the penis that has curved is not necessarily a very happy 15-year-old boy and repairing that 15-year-old boy is a pretty big deal and so the surgery has to be done very carefully it does require quite a bit of training to know how to do it and it has to be done in such a fashion that it does grow with the child so this is a good uh transition to talk to Blen now because Blen was talking about how important she finds it and I find it too that conversations between parent and child start from day one and so this child has had I'm just going to use this case study that we're talking about now and so three four five years old when children start to become aware of their bodies and they may not know that their penis is curved and other people people don't have curved penises so maybe talk about not maybe but please do discuss the communication that should be occurring between mother and child because there's a certain point too when the child's probably not going to want to tell Mom and Dad when he turns S8 or nine because you're talking about a 15-year-old and having to do surgery at 15 and could this be helped when he's 6 Seven 8 n versus getting to really the hormonal ages and take that any way that you'd like to discuss that well I think that it becomes more notable when they're starting to potty train okay because now they're wearing underwear and there's not like hiding in the diaper and so if they're urinating and the stream is going up or the stream is going all over the place the mom wants to know why is my child making such a mess right right simply said but absolutely yeah so you know that's usually when I think okay the conversation has to be made you know it's like well what's going on why are you making such a mess right you know instead of it just being always a boys will be boys yes so at that point is when you start to notice with girls and with boys okay more urinary problems okay because now there an ideal age uh before getting to the age of 15 is there an ideal age that uh this should be corrected prior to really becoming a man so to speak for hypospadius we usually for hyosus specifically six months of age okay but but I'm thinking you had the surgery and then they have to have a resurgery between 15 I'm thinking to myself there's that 14-year gap of you know what I'm saying of when okay I really do need to correct this now before I get to a certain point where it's really uncomfortable and something more dramatic needs to be done well um one of the fundamental tendons of surgery is to follow your patients yeah okay and to make sure that they do well and Bin you know she sometimes sells herself short she's that point person so the parents will call her I may see the patient when they're 18 months of age and say you know things are great why don't you call me if there are problems with toilet training and belind a first point of contact and they call her and they say oh everything's a mess he can't aim maybe he has two streams and that could be what's called a fistula right where it opened up a little bit right and that's how we detect it and so yeah the 15-year-old is a bit of an extreme I've operated on 20-year-olds these are extreme circumstances and the way they got to that point has to do a little bit with the care they had the people they saw and the plans that were communicated to the family okay but if there's a complication from a hypospadia surgery we like to fix that within 6 to 12 months of the initial surgery yeah why not exactly um so we've talked a lot about young men let's talk about the girls um what are some of the more common issues with girls in the area of Urology UTI okay is number one I think and bed and young I mean we talking young young ones some are young yes we do get some that are babies too and what are the causes is that cleanliness in my head you know I'm trying to think is there are some there are some girlfriends of mine that I feel like they always have a UTI like constantly and those that never have them or rarely do so what are some of the common issues and reasons why women have UTI it's not it's not wiping okay it's not that yeah that's the common that's the common thought like keep yourself clean you're not getting U like it's not about that but more common is constipation starting even with babies so physiologically um I know we have a model here I don't know if that's going to show what we're talking about but physiologically why would constipation be something that leads to a UTI because the the rectum if if it's full it's right behind the bladder so it puts pressure on the bladder and the bladder cannot empty so you can imagine the urine that's kind of stuck on the the sides it's just stasis of the urine right there and it's just hanging around so by the time it comes out it could have already become a bacteria plus the bacteria that's more common that we find in UTI is eoli which is comes from the gut okay so those are the two the biggest factors so when a baby has a UTI and again I'm going back to what we talked about in the opening they can't tell you that it hurts and a baby cries for a multiple of reasons right and so I again was reading up today and there's sometimes body cues of maybe faces they make or maybe positions that the babies are are getting into describe what some of those could be that a parent or a grandparent could kind of iBall and say okay there's something going on here well for babies fever is a big one and they're very irritable they very fussy they don't want to eat and so those are big flags that you need to look for in babies okay okay and um I'm trying to think too I don't remember how often when my little ones were little I have a 26-year-old and 21 year old right and there's like well baby checkups and um in general can a UTI go undiagnosed and really become a problem again if the parents have no idea that there's a UTI and and we're talking about little ones that cannot yet vocalize what's happening or going on how common is that and maybe it's not common at all and we don't have to you know spend a lot of time on that well it's pretty rare for it to go undiagnosed okay uh typically what we tell families is for unexplained high fevers when they see their pediatrician and they can't come up with the reason that they should check the urine and it's a very important point in the non- toilet trained child it matters how that urine is collected so sometimes it is very common to put a bag on the G area and then collect the urine as the child urinates that is by definition a contaminated specimen and a bagged specimen is actually only valid if it's negative if it's positive it could be skin is that though to collect the urine I typically we have to use a catheter that's the best way to get a urine specimen in a baby when you are concerned for urinary tract infection so the threshold has to be met we're not suggesting that all children need to be cized but in order to really Define the urinary tract infection it matters how the sample is obtained many patients that come to our Clinic with a history of urinary tract infection actually I've never had one it's always how the sample is obtained and sometimes those patients have contaminated samples and then we have sometimes indiscriminate antibiotic use and we have a lot of issues around that so you ask a very good question and urin tract infection is a diagnosis of exclusion and when it's suspected and there's a high index of Suspicion a catheterized specimen is probably the best specimen for the non- toilet train child boy or girl yeah and very spe specific makes sense um let's talk about renocolic because that was new to me before Today's Show it's like I don't think I've heard of that before so who wants to take that one on so we talk about renocolic so renocolic is a little bit of an ambiguous term uh it is supposed to be defined as pain with the kidney pain with the kidney typically happens in the setting of infection think about someone who has a urot tract infection that spreads to the kidney that can cause pain or renocolic renocolic can also be seen in setting man in like back pain for the child I'm trying to think of of cues that the parents would be looking for children would just cry they'll just cry and they'll tell you that their tummy hurts okay and so again a high index of Suspicion is necessary and there's certain conditions that lend itself towards renocolic for example some of those conditions that we detect prenatally like swollen kidneys swollen kidneys or a history of swollen kidneys and renocolic should prompt a workup or at least a call to a pediatric urologist sometimes stones as they're made and passed down the urinary tract can I think Stones is something old people get children good we live in the desert we drink water drink water drink water hydration is a really really big factor in stones and Stones can happen in children both from causes like dehydration but also from congenital issues as well okay and treatment of renocolic how do you treat it Define the problem we have to define the problem first and often times the first step is an ultrasound and that's actually a really important um point for the folks diagn okay diagnostic area it's very common to get a CT scan okay and that's usually done for adults in children we really want to limit their radiation exposure so typically at a children's hospital the ultrasound is the first step it's non-invasive it doesn't require radiation and in my mind it's the safest test and the biggest bang for your buck a CT scan is very very commonly done and I would discourage its use in children for or diagnosis of renocolic so you bring up a really really good point if you're looking at um the visibility of each one of these scans as a doctor who is recommending perhaps not to do a CT scan um doing an ultrasound versus a CT and the clarity of the vision the the what you would receive in a in a what am I looking for the the image image the Imaging sorry sometimes I lose words how different is a sonogram versus a CT scan when it comes to Imaging and the clarity of the Imaging so it gets back to wanting the best for your child right and in my opinion the best care for your child is a children's hospital where all they do is take care of children because if you go to a hospital that mainly takes care of adults and then sometimes takes care of children like for example an emergency room you're going to have the problems you described the ultrasound may not have the quality of images that you need God versus at a pediatric hospital it will because that's what we do all the time for little people exactly okay that makes sense I like it um question here uh we talked about what could be mistaken for a urinary tract infection actually we haven't really talked about that we' talked a lot about urinary tract infections but what might be mistaken for a urinary tract infection you know bin I'm going to let you do this because we saw about five patients today with exactly this oh hello well there you go taking it straight from work to the dinner table let's consider ourselves a dinner table tonight well a lot of times uh kids will say oh it hurts it hurts to pee but their vagina is all irritated it's all red they sometimes have leakage that sometimes we're examining them and we show the mom look I just opened the legs and the urine just leaked out and so that causes irritation to the skin which is vulvo vaginitis and it's not a UTI but it is irritation of the vagina so describe what vaginitis is if you can Define that so it's the irritation right around the in the vagina and around the vagina so inside the vagina inside and it could be outside also what causes that just constant wetness so yes constant wetness exactly and because the urine especially if you're dehydrated will irritate the skin okay and a lot of kids well um not so much because they're from the south I had one little girl that her grandmother taught her that when she peeded she had to close her legs because only a lady always had her have her legs closed but also the little kids they don't want to fall in the toilet so they're holding on and they're squeezing their legs so if you learn how to pee with your legs closed the urine never quite completely gets yeah and it gets stuck so that's very common and then you have because you have the redness and irritation then the urine is a contaminated specimen and even though it might grow bacteria it may not be a true so let's take this to a practically applied science so potty training chairs and seats right um let's let's I feel like it's the most obvious thing but maybe it's not but when you I can Envision my little ones too when you're in a public bathroom with something literally I remember holding them because they would literally fall right through right so if you have the ability to have a potty trading seats again is this something that's that's even questionable is it even an issue am I just being a nut is a mom who's got old kids at this point no not at all Dr Alum feel free to take that one I I tell a lot of my families that these are problems of the industrialized World it actually doesn't happen when children squat devoid in a hole and these are western style toilets that like you're paying in the Woods ex exactly and so what happens is when the children urinate the urine goes into the vagina which is a potential space it gets held in there and then when it comes out it could be mistaken as incontinence which is not or it may have a smelly or smell to it may have an odor to it and the parents think it's urine attract infection it's just vaginal traing of urine so they make devices where you can put your legs up they make devices like smaller toilet seats and it's just about toileting posture and to make sure the children are comfortable when they void and more relaxed so they're not tightening their pelvic muscles when they void the significance of this is that children who develop dysfunctional habits of voiding sometimes become adults with dysfunctional habits of voiding that can include things like bladder pain frequent urinary tract infections they can carry them for the rest of their lives with these problems that are pretty easily identified and addressed in childhood I really like the wording toilet in posture yeah right it it so describes what you're talking about and so from the get-go and that's something again I as a lay person that's not something I think about but describing it that makes all the sense in the world um let's talk a little bit about we talked about trying to drink a lot of water especially in the desert so in general that's great to do um bladder function so when we talked prior to us beginning this program I was kind of giving you a list of questions that I research and did me says oh this is a good one so what tests are done to check bladder function and I'm going to start there because we're talking about urinary issues in general but we haven't really talked specifically about the bladder and what issues could be going on with the bladder so what what kind of tests do you do for that so to talk about the bladder requires a little bit of an understanding of there two different kinds of Urology there's the basic Pediatric Urology and complex Pediatric Urology so some children are born with conditions that cause the bladder to be abnormal um spinabifida anoral malformations or conditions that actually have an impact on the shape function size or position of the bladder and in order to understand if the bladder is working properly and more importantly if the bladder is functioning in a manner that is safe for the kidneys we have to do bladder function tests and those are called urodynamics okay and we are the only gig in town in terms of El Paso where we do ped rric urodynamics and that's done in the clinic and it's done with the patients awake it involves placing a catheter in the bladder with a special pressure sensor on it and a catheter in the rectum and what you do is you measure the pre pressure in the rectum which is a surrogate for the pressure of the belly you measure the pressure in the bladder and you subtract one for the other which gives us the pressure of the bladder muscle H and that test is done usually with fluoroscopy where we inject contrast and take pictures and we look at how the bladder is functioning and so that's the extreme bladder measurement test for patients who have conditions that are concerning for what's called neurogenic platter and what would those symptoms be and again I'm thinking about people who might be watching this and what would they look for in symptoms with with this so it requires usually an underlying diagnosis okay such as spinabifida anoral malformation bladder extropy and so those are the conditions now there's another bladder test we do called a non-invasive urodynamics where children void into a special commode that has a pressure sensor on it and they have little stickers that it's on their perineum where we can measure their pelvic floor muscles and as they urinate we try to determine if they're emptying their bladder if they have good flow or if while they're voiding they're tightening their muscles when they shouldn't tighten and that is dysfunctional voiding and sometimes we see that in children with constipation the symptoms are usually my four-year-old child was toilet trained and now they're weding themselves all day long or they're weding themselves at night and we've gone through and done everything that's necessary to rule out other problems and then we do a test to see if there's any dysfunctional component of their voiding and that's done with the patient obviously awake no needles nothing invasive just some stickers on the bottom just some stickers on the bottom so I'm just saying cognitive behavior here right it's like it's training them teaching them correct um about the dysfunctional voiding and toilet posturing so um is this something and blend just to bring you into the conversation here something that you're helping teach the parents to teach the kids um and I'm just I'm just trying to think of again when my little ones were little all kinds of things because you can talk about anything with a little one and they're not embarrassed because they don't know they don't have that that little key in their head yet so um when you're trying to teach parents to teach their children about posturing about uh voiding correctly and not dysfunctionally how does that training occur well when we do the Euro flow we show them this this is what we're looking at and this is what your bladder capacity should be and this is where their your son is at or your daughter and let's say that their capacity should be 200 but at 97 they already had urgency so already you're identifying a problem and then when they flowed you could see that the flow was intermittent like they did not have a good flow so that they are tightening their and does a child know that they're tightening that's where it is I'm trying to think of cognitively how to get someone who's just potty training right let's say what let's say three-ish right how how do you teach that like how how are you describing to the little one what are you feeling and can they describe it back to you and why are they tightening why are they they're not tightening and how do you train them like I'm I'm super curious about how how that would they're video games actually there we go this is this is what I'm talking about I'm like how how does this this work into the okay so talk about the video games so the pressure sensors the stickers on the bottom uh will register and they can be programmed into a video game to teach the kids how to tighten how to relax and usually we don't do this on three-year-olds you want to have the child a little bit older before we do this it's called biof feedback okay it's basically training them how to void in a manner that's more consistent with getting urine out so throw me an age MIM menos for Bio feedback the youngest I would reasonably expect success would be five okay but even that's pushing it we typically do around five or six okay and that's truly when they can be descriptive as well right to kind of talk about what's happening what's going on um I'd like to we can get all kinds of stuff here what I really want to do is talk about non-complex and complex so um we talked again prior to the show that prior to the service line what was happening in El Paso were surgeries and just issues that were being treated that were non-complex but now there are complex issues being treated um can you describe a little bit more of what that means so the the most invasive thing that we do is urinary tract reconstruction okay and so these are patients who are born with Bladers that leak meaning they have no sphincter and so we have to create a mechanism in which the bladder can hold without them being a diapers sphincter correct okay so it's not great to be seven years old and still in diapers when your classmates are not so we provide the children with a sense of normaly and it's a big operation and so sometimes it involves closing the bladder neck sometimes it involves reconstructing it such that it doesn't leak we make bladders bigger using pieces of intestine we create channels where instead of catheterizing through their urethra meaning their penis or their urethra in a female we cize through a special opening on the abdomen and some of the patients have fecal incontinence and you know just doing your logic reconstruction and then leaving a child soiling themselves in diapers is not the okay thing to do and so we do things like create little openings where they can give themselves enemas while sitting on their toilet from a small little opening in their belly so they can do themselves so the way that you're reconstructing all those areas that they're again it's a whole teaching moment correct and in the past they'd have to go to other cities Etc so this is relatively new in El Paso and I'd love for you to to kind of take that forward so um since I started in El Paso back in March we have now done four of those cases okay the patients are all doing very well two of those patients are El Paso winds that actually were on the surgical schedule at other hospitals in different cities but once they found out they had the opportunity to stay in El Paso they stayed in El Paso we actually did the final test on one of the patients today and I'm delighted to say that she is dry and clean and first time in her life oh and how old is she she's seven she's seven that seem so old two other patients came actually from out of town one patient came from New Jersey a patient that I had seen when I was in New York and another patient came from South Carolina for these operations these are typical long operations sometimes up to 14 15 hours oh my okay and uh they're pretty labor intense and resource intense operations but the most important thing is for the community of Al Paso we now have the ability to take care of the patients here so I'm thinking if this is a 14-hour mosos type uh how how much planning and how much pre-operative do you have to do or is it all literally taken care of in the operating room that day like con I was was going to say because reconstructing there's there's a lot of pre-planning for that maybe describe uh not so much in detail because of the time but describe what it is that you have to pre-plan these are reconstructive surgeries correct that to me it seems incredibly complex it is very complex and it starts off with obviously defining the problem doing the urodynamic studies and medical management that is the the beginning of any what every pediatric urologist does sometimes we try and medically manage the bladder with medications and catheterization to determine if we can make the bladder grow if the patient can be dry if the kidneys can be safe we do all those things for a period of months to sometimes years before we do the Reconstruction I don't do these reconstructions until the children are anywhere between four and six years of age okay we usually wait um the reason we pick that is I like my kids to be clean and dry by SE by second grade and um a lot of people will not not want to talk about this sometimes the patients are in wheelchairs and they are in diapers and some folks have normalized that but I don't think that being clean and dry is something elective I think every child deserves that and sometimes there's a safety issue as well sometimes people are incontinent because of some bad bladder stuff and we do these reconstructions and identify it medically to help those children so they can lead normal life and productive lives and and how does that conversation start like and I I love that you're using the word we don't want to normalize that you know that if it becomes normalized and now you're in a family situation where oh that's just the way it is how as a doctor who sees this going on who who's the one that starts that conversation is it usually the parents that start the conversation is it the child themselves perhaps is it the doctor just saying hey these are some options um in general how does that that usually come about it really depends on the um people around the child okay um there are sometimes socioeconomic um barriers uh sometimes there's a reticence to really want to address things sometimes there's a reticence to understand what the family is going through so unfortunately you know sometimes families with the least means have children with the most needs right and it really requires um kind of a fundamental rethinking of how to help families we have to first Define what their barriers are whether it's education whether it's being able to get to the clinic and explain to them that here are your options this is possible for your child and so it really depends on how we get that message out there but what I love are the disruptive Technologies like Facebook and the family support groups because I'm a big fan of calling Physicians to task right and that's kind of where the question's coming from right it's like how does that conversation start who brings it up who uh unnormalized certain things if that's even a proper way of describing it um so I like the way you talked about that um I would love to go to this great acronym the ca kuut congenital anomalies of the kidney urinary tract urer bladder and urea that's a that's a lot to say right uh but the the key word here is congenital correct and so let's just open the conversation about this so identifying prior to birth etc etc exactly the best way to think about this is excuse me for children with kidney disease in the United States the cause of renal failure and kidney disease in children the United States 50% of the time is related to a kaket condition it's very different than an adult an adult who has kidney disease and kidney failure is usually because of some some anomaly for example high blood pressure diabetes in children the script is flipped it's khet now not every child with khit will develop kidney disease okay but it is important to understand and diagnose khit so that you can prevent prevent well you can stop preventable renal harm and so caket Spectrum anomalies include things like reflux urine that goes backwards up into the kidneys or swelling of the kidneys and those are examples of things that sometimes we prenatally mostly the swelling and the important aspect of the acronym is that it really helps people understand the diagnosis so there can be a lifelong follow-up plan and again kind of putting forth the importance of the medical management and followup of the patients so treatment um when you say lifelong following what does that mean in treatment going forward like when you say following describe the following from again this is birth and now someone who's 25 years old so full-on adult okay how do you follow this kaket typically you follow from a kidney standpoint with ultrasounds and blood draws and measurement of kidney function and so let's take the extreme example there used to be something called dles crisis where a young adult 18-year-old would go to college and discover two things not necessarily in the disorder but coffee and beer and they would have an underlying obstruction of their kidney and would make a large amount of urine because of coffee and beer right and present to the emergency room in pain and lo and behold they would have swelling of their kidney now and they've never noticed this before it's never been an issue before but now they're in collagen boom it's an issue and so we now have kind of eliminated that because of prenatal testing and so those are patients who are followed sometimes repaired or watched depending on the kind of swelling of the kidney and they may have a plan for the future that if this happens then we need to do this okay and we try and explain to our patients as they've become young adults to be able to advocate for themselves and to say these are the things that need to be followed see I and I'm thinking to myself too again I'm have a 21y old boy and would he even bring this up to me would he bring it up to a doctor just all of a sudden it's like man I've got a lot of urine in me and I I guess so when and how do you find young ones who are college age bringing this up or is it just something that and they're not going to go to the doctor I mean how often do they they don't go to the doctors yearly until you start screening stuff right I mean how how would they know that they have an issue is I guess the question is there pain involved um well that gets back to the renocolic question and so yeah so typically renocolic when it's severe will bring someone to the emergency room and the diagnostic test will then make the evaluation that dles crisis phenomenon is really a phenomenon of the 1970s and 1980s it's really something that doesn't happen it's very rare to have a denovo presentation of a bat problem okay but you know with any sort of young adult typically when there's a partner involved girlfriend boyfriend or otherwise they tend to tow the line and do as they're told and come to the doctor and there's a problem partners are so important when it comes to Stu in so many different medical issues like hey you're having an issue go check it out um we are at about the 10 minute Mark of the show ending so what I'd like to do Blen um she's like what um is there anything that we have not yet there's so much to cover here I we can do like hours and hours on this program is there anything that for tonight we haven't covered yet or something that maybe we touched Bas on that you'd like to cover some more before we start closing up it goes by so fast I know I know it does it does um but I'd love to make sure that what you all came here to do is something you came here to do um is there anything that we haven't discussed yet that you'd like to bring up well we haven't talked about testicles okay we haven't you're right so as they're let's talk about testicles this is a PBS program this is this is a place you can do it right so yeah let's do so a lot of premature babies their testicles won't drop so the pediatricians are pretty good about looking for testicles from the time that they're born but they do get referred to us cuz sometimes the babies are very chunky and you can't quite find the testicle cuz they're kind of fat the little fat pad obscure as the exam the testical so that's important to know because going to interject a question here because I don't know this question uh when are they supposed to drop is down if they're not down by three months they're not going to come down if they're not down by 3 months they're not going to come down look at the stuff I'm learning okay so now what down and somebody's four or five months old now what so now they need surgery okay but they won't get surgery until they're 6 months but it's still has to already be scheduled and be planned okay I'm going to again the brand new mama who doesn't even know to look for this and this is where I guess the the checkups the the well baby checkups come in right which is super duper important um how would a mother who maybe didn't go to the doctor and do checkups are there any physiological medical issues that are happening as far as urinating or anything that that a mom would know that the testicles haven't dropped I don't know how I don't know how to ask that question I don't a of a scrotum looks normal and they wouldn't know if they're not feeling the testicles okay so they may not know they may not know so what happens then that now a child is seven eight nine months old testicles still haven't dropped nobody knows about it well hopefully when they go for their well baby check the pediatrician because they're very good they will notice so this may be a show to Advocate go go get your W baby checks yes yes for sure and they will refer them to us and we you know we take it from there okay but as they get older they can have testicular pain just from constipation because that poop is so predominant in that area that it's pushing on the testicle okay okay so have there been any um again just think of a case study where you know child I don't even know what age where the testicles have not yet dropped the child parents don't know and you're into two or three or four years of life if has that happened yes and if it has happened what do you do now and what are the issues that are occurring with the child well you can still do surgery okay you know sometimes the child will be seven and they just for a variety of reasons um weren't diagnosed we like like to do surgery early their early surgery tends to preserve fertility and prevent problems in the future although that data is not 100% great data but we can do work at apexes in patients that are seven the most extreme sometimes you'll see patients that come in at 18 19 oh and if the testicles aren't down and if they're not able to be palpated sometimes we remove those testicles because at that point there may be a slight increase risk of malignancy so I'm embarrassed to ask this because I'm trying to visualize this so the testicles are where then if they're not dropped they're literally at that the the level you were talking about constipation so they're still kind of hanging out in the cavity and when somebody's 189 and they have not noticed this this whole time and I guess again if you're not if there's no locker room talk if there's no nobody to compare yourself to which again that that goes back to the very beginning opening statement right it's like uh disruptors like how would you know if you don't know how do you know what you don't know in a situation like this with the internet now the internet know things right right you know sometimes it it just has to do with medical literacy and access to care I mean it's it's a very difficult thing to wrap your head around but sometimes people are born into circumstances that they don't have the same opportunities that the rest of the patients have right um either way it's not something to be scared of ashamed of these are all conditions that can be fixed really at any point I didn't didn't mean to talk about removing testicles I just gave that as an example and I'm just thinking too uh just in general the embarrassment that circle around the word genitals you know that that take that away and let's really discuss these things absolutely on that note now it's your turn is there something that we haven't touched base on yet that you'd like to bring up before we start wrapping up specifically I just really want to get the message across Ross that these are really not part of polite conversation but it should be Pediatric Urology conditions or something people should feel confident and comfortable talking about normalizing peeing and pooping with your child is really important normalizing Anatomy normalizing sexual function as the time goes on and normalizing the ability to ask questions when the child perceives something is incorrect or something is wrong I think is is the most important thing to get across you know we're plumbers and we take care of things that people don't really talk about at cocktail parties but these are really important aspects of life and they can have significant psychosocial impacts as time goes on I'm in full agreement so we uh Diego knows this because it was part of our conversation we had at lunch the other day when we were talking about our yearly uh Gathering but this program started 26 years ago I was at the American Cancer Society and nobody wanted that's why I said about testicles right nobody wanted to talk about testicular cancer and that is kind of a young I know it's out of the world of Pediatrics but it's kind of a younger man's issue and so uh I approached PBS at that time and it was one of those things like you can't say testicles out loud and like men would literally start shifting in their chairs and um so I'm so glad that here we are 26 years later and we're talking about this openly and again with social media that these are just things that you can access and I think if kids have curiosity now blessings and curses of phones I get it but some of the blessings are that you kind of can go research sometimes it's not good research but in general it's at least out there to be found there are a whole host of books about like Everybody poops and they're right one of my patients mothers actually wrote a book about urinary tract reconstruction little bunny has bladder surgery right I I love that this is this is a thing I want to say thank you again Dr Alam again pediatric urologist at the El Paso children's hospital and balent tasis nurse practitioner practic practitioner practitioner um to testicular that's also the one of those that doesn't come out easily if you uh only caught part of this program or you want to see this in whole once again you can do it in three different places you can go to PBS Al paso.

org and you can find it there again just look up the word the El Paso physician epcms which is the website for the El Paso County Medical Society that's EPC ms.com and then good old fashion YouTube um youtube.com and then in there you can write and and use the word the so the El Pasa pH the El Pasa Phan and usually that pops up and the great thing about going to those platforms is that yes we're talking about Pediatric Urology but you can find all the programs that the alas physician the alas counter Medical Society has been doing for years and you'll have a backlog on all of that and that's good for you guys to go back to and look too um if you feel like we discussed something today that one of your patients can benefit from they can go back and kind of listen to this conversation so I thank you guys very much for being here and again thank thank you to the El Paso children's hospital um and the El Paso County Medical Society for again bringing the show to you each and every month I'm Katherine Berg and this has been the El Paso [Music] physician