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Dr. Zachary Liss, M.D. on Pediatric Urology at MIU.

Urology Specialties, Treatments & Technology
Urinary Tract Infections
Urinary tract infections (UTIs) affect about 3 percent of children in the United States every year. Throughout childhood, the risk of a UTI is 2 percent for boys and 8 percent for girls. UTIs account for more than 1 million visits to pediatrician’s offices every year. The symptoms are not always obvious to parents, and younger children are usually unable to describe how they feel. Recognizing and treating urinary tract infections is important. Untreated UTIs can lead to serious kidney problems that could threaten the life of your child.

How do you find out whether your child has a urinary tract infection?

Only by consulting a health care provider can you find out for certain whether your child has a urinary tract infection.

Some of your child’s urine will be collected and examined. The way urine is collected depends on your child age. If the child is not yet toilet trained, the health care provider may place a plastic collection bag over your child’s genital area. It will be sealed to the skin with an adhesive strip. An older child may be asked to urinate into a container. The sample needs to come as directly into the container as possible to avoid picking up bacteria from the skin or rectal area. A doctor or nurse may need to pass a small tube into the urethra. Urine will drain directly from the bladder into a clean container through this tube, called a catheter. Sometimes the best way to get the urine is by placing a needle directly into the bladder through the skin of the lower abdomen. Getting urine through the tube or needle will ensure that the urine collected is pure.

Some of the urine will be examined under a microscope. If an infection is present, bacteria and sometimes pus will be found in the urine. If the bacteria from the sample are hard to see, the health care provider may place the sample in a tube or dish with a substance that encourages any bacteria present to grow. Once the germs have multiplied, they can then be identified and tested to see which medications will provide the most effective treatment. The process of growing bacteria in the laboratory is known as performing a culture and often takes a day or more to complete.

The reliability of the culture depends on how long the urine stands before the culture is started. If you collect your child’s urine at home, refrigerate it as soon as it is collected and carry the container to the health care provider or lab in a plastic bag filled with ice.

What tests may be needed after the infection is gone?

Once the infection has cleared, additional tests may be recommended to check for abnormalities in the urinary tract. Repeated infections in abnormal urinary tracts may cause kidney damage. The kinds of tests ordered will depend on your child and the type of urinary infection. Because no single test can tell everything about the urinary tract that might be important, more than one of the following tests may be needed:
Kidney and bladder ultrasound.
An ultrasound test examines the kidney and bladder using sound waves. This test shows shadows of the kidney and bladder that may point out certain abnormalities. However, this test cannot reveal all important urinary abnormalities. It also cannot measure how well a kidney works.
Voiding cystourethrogram (VCUG). This test examines the urethra and bladder while the bladder fills and empties. A liquid that can be seen on x rays is placed into the bladder through a catheter. The bladder is filled until the child urinates. This test can reveal abnormalities of the inside of the urethra and bladder. The test can also determine whether the flow of urine is normal when the bladder empties.
Intravenous pyelogram. This test examines the whole urinary tract. A liquid that can be seen on x rays is injected into a vein. The substance travels into the kidneys and bladder, revealing possible obstructions.
Nuclear scans. These tests use radioactive materials that are usually injected into a vein to show how well the kidneys work, the shape of the kidneys, and whether urine empties from the kidneys in a normal way. Each kind of nuclear scan gives different information about the kidneys and bladder. Nuclear scans expose a child to about the same amount of radiation as a conventional x ray. At times, it can even be less.
Computed tomography (CT) scans and magnetic resonance imaging (MRI). These tests provide 3-D images and cross-sections of the bladder and kidneys. With a typical CT scan or MRI machine, the child lies on a table that slides inside a tunnel where the images are taken. If the child’s infection is complicated or difficult to see in other image tests, a CT scan or MRI can provide clearer, more detailed images to help the doctor understand the problem.

What abnormalities lead to urinary problems?

Many children who get urinary tract infections have normal kidneys and bladders. But if a child has an abnormality, it should be detected as early as possible to protect the kidneys against damage. Abnormalities that could occur include the following:
Vesicoureteral reflux (VUR). Urine normally flows from the kidneys down the ureters to the bladder in one direction. With VUR, when the bladder fills, the urine may also flow backward from the bladder up the ureters to the kidneys. This abnormality is common in children with urinary infections.
Urinary obstruction. Blockages to urinary flow can occur in many places in the urinary tract. The ureter or urethra may be too narrow or a kidney stone at some point stops the urinary flow from leaving the body. Occasionally, the ureter may join the kidney or bladder at the wrong place and prevent urine from leaving the kidney in the normal way.
Dysfunctional voiding. Some children develop a habit of delaying a trip to the bathroom because they don’t want to leave their play. They may work so hard at keeping the sphincter muscle tight that they forget how to relax it at the right time. These children may be unable to empty the bladder completely. Some children may strain during urination, causing pressure in the bladder that sends urine flowing back up the ureters. Dysfunctional voiding can lead to vesicoureteral reflux, accidental leaking, and UTIs.

Do urinary tract infections in children have long-term effects?

Young children are at the greatest risk for kidney damage from urinary tract infections, especially if they have some unknown urinary tract abnormality. Such damage includes kidney scars, poor kidney growth, poor kidney function, high blood pressure, and other problems. For this reason it is important that children with urinary tract infections receive prompt treatment and careful evaluation.

Enuresis (Bed Wetting)
Urinary Incontinence in Children

Parents or guardians of children who experience bedwetting at night or accidents during the day should treat this problem with understanding and patience. This loss of urinary control is called urinary incontinence or just incontinence. Although it affects many young people, it usually disappears naturally over time, which suggests that incontinence, for some people, may be a normal part of growing up. Incontinence at the normal age of toilet training may cause great distress. Daytime or nighttime incontinence can be embarrassing. It is important to understand that many children experience occasional incontinence and that treatment is available for most children who have difficulty controlling their bladders.

How does the urinary system work?

Urination, or voiding, is a complex activity. The bladder is a balloon-like organ that lies in the lowest part of the abdomen. The bladder stores urine, then releases it through the urethra, the canal that carries urine to the outside of the body. Controlling this activity involves nerves, muscles, the spinal cord, and the brain.
The bladder is composed of two types of muscles: the detrusor, a muscular sac that stores urine and squeezes to empty; and the sphincter, a circular group of muscles at the bottom or neck of the bladder that automatically stay contracted to hold the urine in and automatically relax when the detrusor contracts to let the urine into the urethra. A third group of muscles below the bladder (pelvic floor muscles) can contract to keep urine back.
A baby’s bladder fills to a set point, then automatically contracts and empties. As the child gets older, the nervous system matures. The child’s brain begins to get messages from the filling bladder and begins to send messages to the bladder to keep it from automatically emptying until the child decides it is the time and place to void.
Incontinence happens less often after age 5: About 10 percent of 5-year-olds, 5 percent of 10-year-olds, and 1 percent of 18-year-olds experience episodes of incontinence. It is twice as common in boys as in girls.
Failures in this control mechanism result in incontinence. Reasons for this failure range from simple to complex.

What causes nighttime incontinence?

After age 5, wetting at night often called bedwetting or sleepwetting is more common than daytime wetting. Experts do not know what causes nighttime incontinence. Young people who experience nighttime wetting are usually physically and emotionally normal. Most cases probably result from a mix of factors including slower physical development, an overproduction of urine at night, a lack of ability to recognize bladder filling when asleep, and, infrequently, anxiety. For many, there is a strong family history of bedwetting, suggesting an inherited factor.

  • Slower Physical Development – Between the ages of 5 and 10, bedwetting may be the result of a small bladder capacity, long sleeping periods, and underdevelopment of the body’s alarms that signal a full or emptying bladder. This form of incontinence will fade away as the bladder grows and the natural alarms become operational.
  • Excessive Output of Urine During Sleep – Normally, the body produces a hormone that can slow the production of urine. This hormone is called antidiuretic hormone, or ADH. The body normally produces more ADH at night so that the need to urinate is lower. If the body doesn’t produce enough ADH at night, the production of urine may not be slowed down, leading to bladder overfilling. If a child does not sense the bladder filling and awaken to urinate, then wetting will occur.
  • Anxiety – Experts suggest that anxiety-causing events occurring in the lives of children ages 2 to 4 might lead to incontinence before the child achieves total bladder control. Anxiety experienced after age 4 might lead to wetting after the child has been dry for a period of 6 months or more. Such events include angry parents, unfamiliar social situations, and overwhelming family events such as the birth of a brother or sister. Incontinence itself is an anxiety-causing event. Strong bladder contractions leading to leakage in the daytime can cause embarrassment and anxiety that lead to wetting at night.
  • Genetics – Certain inherited genes appear to contribute to incontinence. In 1995, Swedish researchers announced they had found a site on human chromosome 13 that is responsible, at least in part, for nighttime wetting. If both parents were bedwetters, a child has an 80 percent chance of also being a bedwetter. Experts believe that other, undetermined genes also may be involved in incontinence.
  • Obstructive Sleep Apnea – Nighttime incontinence may be one sign of another condition called obstructive sleep apnea, in which the child’s breathing is interrupted during sleep, often because of inflamed or enlarged tonsils or adenoids. Other symptoms of this condition include snoring, mouth breathing, frequent ear and sinus infections, sore throat, choking, and daytime drowsiness. In some cases, successful treatment of this breathing disorder may also resolve the associated nighttime incontinence.
  • Structural Problems – Finally, a small number of cases of incontinence are caused by physical problems in the urinary system in children. Rarely, a blocked bladder or urethra may cause the bladder to overfill and leak. Nerve damage associated with the birth defect spina bifida can cause incontinence. In these cases, the incontinence can appear as a constant dribbling of urine. Certain inherited genes appear to contribute to incontinence. In 1995, Swedish researchers announced they had found a site on human chromosome 13 that is responsible, at least in part, for nighttime wetting. If both parents were bedwetters, a child has an 80 percent chance of also being a bedwetter. Experts believe that other, undetermined genes also may be involved in incontinence.
  • Obstructive Sleep Apnea – Nighttime incontinence may be one sign of another condition called obstructive sleep apnea, in which the child’s breathing is interrupted during sleep, often because of inflamed or enlarged tonsils or adenoids. Other symptoms of this condition include snoring, mouth breathing, frequent ear and sinus infections, sore throat, choking, and daytime drowsiness. In some cases, successful treatment of this breathing disorder may also resolve the associated nighttime incontinence.
  • Structural Problems – Finally, a small number of cases of incontinence are caused by physical problems in the urinary system in children. Rarely, a blocked bladder or urethra may cause the bladder to overfill and leak. Nerve damage associated with the birth defect spina bifida can cause incontinence. In these cases, the incontinence can appear as a constant dribbling of urine.

What causes daytime incontinence?

Daytime incontinence that is not associated with urinary infection or anatomic abnormalities is less common than nighttime incontinence and tends to disappear much earlier than the nighttime versions. One possible cause of daytime incontinence is an overactive bladder. Many children with daytime incontinence have abnormal elimination habits, the most common being infrequent voiding and constipation.

  • An Overactive Bladder – Muscles surrounding the urethra the tube that takes urine away from the bladder – have the job of keeping the passage closed, preventing urine from passing out of the body. If the bladder contracts strongly and without warning, the muscles surrounding the urethra may not be able to keep urine from passing. This often happens as a consequence of urinary tract infection (UTI) and is more common in girls.
  • Infrequent Voiding – Infrequent voiding refers to a child’s voluntarily holding urine for prolonged intervals. For example, a child may not want to use the toilets at school or may not want to interrupt enjoyable activities, so he or she ignores the body’s signal of a full bladder. In these cases, the bladder can overfill and leak urine. In addition, these children often develop UTIs, leading to an irritable or overactive bladder.

Other Causes

Some of the same factors that contribute to nighttime incontinence may act together with infrequent voiding to produce daytime incontinence. These factors include

  • small bladder capacity
  • structural problems
  • anxiety-causing events
  • pressure from a hard bowel movement (constipation)
  • drinks or foods that contain caffeine, which increases urine output and may also cause spasms of the bladder muscle, or other ingredients to which the child may have an allergic reaction, such as chocolate or artificial coloring

Sometimes overly strenuous toilet training may make the child unable to relax the sphincter and the pelvic floor to completely empty the bladder. Retaining urine, or incomplete emptying, sets the stage for UTIs.

What treats or cures incontinence?

  • Growth and Development

Most urinary incontinence fades away naturally. Here are examples of what can happen over time:

  • Bladder capacity increases.
  • Natural body alarms become activated.
  • An overactive bladder settles down.
  • Production of ADH becomes normal.
  • The child learns to respond to the body’s signal that it is time to void.
  • Stressful events or periods pass.

Many children overcome incontinence naturally, without treatment as they grow older. The number of cases of incontinence goes down by 15 percent for each year after the age of 5.

  • Medications

Nighttime incontinence may be treated by increasing ADH levels. The hormone can be boosted by a synthetic version known as desmopressin, or DDAVP, which is available in pill form, nasal spray, or nose drops. Desmopressin is approved for use in children.
Another medication, called imipramine, is also used to treat sleepwetting. It acts on both the brain and the urinary bladder. Researchers estimate that these medications may help as many as 70 percent of patients achieve short-term success. Many patients, however, relapse once the medication is withdrawn.
If a young person experiences incontinence resulting from an overactive bladder, a doctor might prescribe a medicine that helps to calm the bladder muscle. This medicine controls muscle spasms and belongs to a class of medications called anticholinergics.

  • Bladder Training and Related Strategies

Bladder training consists of exercises for strengthening and coordinating muscles of the bladder and urethra, and may help the control of urination. These techniques teach the child to anticipate the need to urinate and prevent urination when away from a toilet. Techniques that may help nighttime incontinence include

  • determining bladder capacity
  • drinking less fluid before sleeping
  • developing routines for waking up

Unfortunately, none of these techniques guarantees success.
Techniques that may help daytime incontinence include

  • urinating on a schedule – timed voiding – such as every 2 hours
  • avoiding caffeine or other foods or drinks that you suspect may contribute to your child’s incontinence
  • following suggestions for healthy urination, such as relaxing muscles and taking your time

Moisture Alarms

At night, moisture alarms can awaken a person when he or she begins to urinate. These devices include a water-sensitive pad worn in pajamas, a wire connecting to a battery-driven control, and an alarm that sounds when moisture is first detected. For the alarm to be effective, the child must awaken as soon as the alarm goes off, go to the bathroom, and change the bedding. Using alarms may require having another person sleep in the same room to awaken the bedwetter.

Kidney Swelling
Types of Nephritis:

Acute Nephritis – Acute nephritic syndrome is a group of disorders that cause inflammation of the internal kidney structures (specifically, the glomeruli). Acute nephritic syndrome is often caused by an immune response triggered by an infection or other disease.

The inflammation disrupts the functioning of the glomerulus, which is the part of the kidney that controls filtering and excretion. This disruption results in blood and protein appearing in the urine, and the build up of excess fluid in the body. Swelling results when protein is lost from the blood stream. (Protein maintains fluid within the blood vessels, and when it is lost the fluid collects in the tissues of the body). Blood loss from the damaged kidney structures leads to blood in the urine.

Acute nephritic syndrome may be associated with the development of high blood pressure, inflammation of the spaces between the cells of the kidney tissue, and acute kidney failure.

 

Symptoms

  • Blood in the urine (urine appears dark, tea colored, or cloudy)
  • Blurred vision
  • Decreased urine volume (little or no urine may be produced)
  • General aches and pains ( joint pain, muscle aches)
  • General ill feeling (malaise)
  • Headache
  • Slow, sluggish, lethargic movement
  • Swelling of the face, eye socket, legs, arms, hands, feet, abdomen, or other areas

Chronic Nephritis – Is a chronic inflammation of the tissues of the kidney. It is caused by a wide variety of etiological factors. The disease is frequently associated with a slow, progressive loss of kidney function. It is usually discovered accidentally, either by routine urinalysis (tests done to check kidney function) or during a routine physical checkup when anemia, hypertension, or laboratory findings (elevated serum creatinine and blood urea nitrogen) are discovered.

Ureteral & Kidney Stones
The ureter is a tubular structure that connects the kidney to the bladder. Stones that develop within the kidney will sometimes migrate down the ureter. Most stones less than 6 mm in size will eventually pass into the bladder. However, larger stones may become lodged within the ureter.

Signs and Symptoms of Urethral Stone

Pain in the lower abdomen, either on the right of left, may be caused by kidney stones or ureteral stones. Fragments that become lodged in the lower half of the ureter produce pain that is usually constant and may spread into the genital region. Simultaneously, there may be low back pain and blood in the urine frequently may occur.

Michigan Institute of Urology's Pediatrics Department
Michigan Institute of Urology is pleased to recognize the addition of pediatric urologist Zachary Liss, M.D. A born and bred metro Detroiter, Dr. Liss completed his Urology residency at Wayne State University and his fellowship training in pediatric urology at Cincinnati Children’s Hospital Medical Center, one of the top rated children’s hospitals in the country. Dr. Liss is thrilled to be home, helping take care of children and families in Southeast Michigan.

Dr. Liss specializes in all aspects of routine and complex pediatric urology. He has a special interest in the use of minimally invasive surgery for a variety of pediatric urologic conditions. Specifically, Dr. Liss specializes in pediatric robotic urologic surgery. Robotic surgery has been shown to provide equal patient outcomes to conventional open surgery with potentially less postoperative pain, shorter hospital stay and less scaring in both infants and older children. Specific procedures include pyeloplasty, partial nephrectomy, ureteroureterostomy and ureteral reimplantation.

Dr. Liss also has a keen interest in complex pediatric urology and pediatric genitourinary reconstructive surgery. Management of neurogenic bladder is certainly a difficult and complex issue, but is key to preserving long term kidney function in this population of children. They require regular follow-up and occasionally surgeries to help preserve kidney function and improve quality of life. Such procedures include continent catheterizable channels (Mitrofanoff), bladder augmentations and continence procedures.

Jennifer Starrs, NP works alongside Dr. Liss. Jennifer’s unique background working at Northwestern Children’s Hospital in Chicago as a pediatric nephrology nurse practitioner makes her an extremely valuable asset in the field of pediatric nephrology. Jennifer concentrates on pediatric voiding dysfunction and stone disease. Any child or parent that meets her understands how truly special she is.

We approach voiding dysfunction on an individual basis. Each patient is unique and requires different workups and treatments. One must recognize the impact of incontinence on both the patient and family. Any combination of lifestyle modification, treatment of constipation, change in voiding habits and medication may be needed. We have also seen great success with pelvic floor physical therapy and biofeedback in appropriately selected patients.

Dr. Liss has authored peer reviewed publications and made numerous presentations at local, regional and national meetings. His research has focused on various aspects of pediatric urology including kidney development, minimally invasive surgical techniques and pediatric genitourinary reconstruction.

Dr. Liss’ philosophy for patient care is based on the development of a trusting relationship between patient, family and physician where all parties partner for the best treatment outcome for the patient. He feels it is crucial that the patient and family fully understand their condition in order to create an appropriate and successful care plan. Dr. Liss strongly believes that open, accessible communication and partnership with both primary care providers and parents are key to providing best patient care and ideal outcomes.

Dr. Liss is married with 3 young children. When not working or with his family, he enjoys golf, fishing, skiing and hockey.