What is Paediatric Urology?
Paediatric Urology is the Surgical Specialty that deals with problems with the genitourinary system in children.
The genitourinary system is made up of the Kidneys, Ureters (tubes that run between the kidney and the bladder), the Bladder and the Urethra (pee tube), as well as the genitalia in boys and girls.
What conditions are managed by a Paediatric Urologist?
Paediatric Urologists are experts at managing a wide range of problems, including:
Inguinal Hernias and Hydroceles - These are very common findings in young people.
Undescended Testicles - The testicle develops inside the tummy and then comes down to the scrotum. If it does not come down properly then this needs to be assessed and treated.
Foreskin Problems (eg non retractile foreskin) - Consultations for foreskin problems are very common. It may be that the child has a non retractile foreskin - this can be normal or it can be caused by a disease or trauma in which case it needs treatment. It may be that there is a hooded foreskin and a Paediatric Urologist will discuss the possible treatments for this.
Problems with the penis (e.g. Hypospadias) - A major part of Paediatric Urology is managing congenital problems with the penis. This includes hypospadias (where the pee tube doesn’t open in the right place) or a buried penis. Paediatric Urologists are experts in how to manage these problems.
Hydronephrosis - this is a condition where there is fluid on the kidney and causes the kidney to be dilated. There are a number of reasons why a kidney can be swollen with a hydronephrosis. A Paediatric Urologist can investigate the cause and discuss what (if any) treatment options there are.
Duplex Kidneys - A duplex kidney is formed during development of the kidney before a baby is born. Effectively there are 2 separate working parts to the kidney, instead of one.
Pelvic Kidney - This is a condition where the kidney is found in the pelvis. It is caused during development of a baby.
Developmental Abnormalities of the Kidney
Multicystic Dysplastic Kidney (MCDK) - This is a condition where a kidney has not developed properly, and does not work.
Vesico-Ureteric Reflux (VUR) - In this condition urine goes from the bladder up to the kidney and can cause kidney damage. Normally there is a valve that stops urine going back up the ureter.
Hydroureter - This describes where the ureter (tube between the kidney and the bladder) is swollen. It can occur for a number of reasons (e.g. Vesico-ureteric reflux or narrowing where the ureter joins the bladder). A Paediatric Urologist can investigate, diagnose and offer treatment.
Kidney stones - Just like with adults children can develop kidney stones. There are a number of treatments that can be used to treat kidney stones.
Urinary Incontinence and Overactive bladder - The way the bladder works can have a major consequences for quality of life. This can affects the child and the family. A major part of paediatric urology is to assess the way the bladder is working and to support children to control the bladder. There are some surgical options for managing functional bladder problems, but the majority of patients are managed without any surgery. Paediatric urologists can perform Urodynamics Tests in order to accurately diagnose what is wrong with the bladder.
Urinary Tract Infections (UTI) - Many UTIs are due to the way the bladder works in young people. This is especially true for children with recurrent UTIs.
Neuropathic Bladder - In some young people with problems with the spinal cord (such as Spina Bifida or MS) the way the bladder works is affected. This is called a Neuropathic Bladder. As well as the bladder the bowel can also be affected. A Paediatric Urologist should be involved with the care of all patients with a neuropathic bladder. Initially they ensure that the kidneys are safe. In the long term they will help the young person become clean, dry and independent.
Posterior Urethral Valves - This is the commonest cause of Bladder Outlet Obstruction (blockage to urine leaving the bladder). It can cause life long issues with the kidneys and the bladder. A Paediatric Urologist will look after young people with Posterior Urethral Valves throughout their childhood.
Narrowing of the pee tube (urethral Strictures)
Haematuria (Blood in the urine) - Haematuria is a symptom. It is not a diagnosis. A number of causes of Haematuria will be managed by a Paediatric Urologist. They tend to be the cases where the blood can be seen in the urine.
As well as these common conditions there are some other things that Paediatric Urologists manage including:
- Traumatic injury to the genitourinary tract
- Cancers of the Genitourinary tract
- Some rare congenital problems such as Cloaca or Bladder Exstrophy
- Kidney Transplants
- Antenatal Counseling
Further information can be found on my Clinical Conditions page.
How is Paediatric Urology Organised in the UK?
Some Adult Urologists will see children with urology problems, such as undescended testes and foreskin problems. Any child with a more complex issue will often be referred to a specialist Paediatric Urologist.
Paediatric Urology is a very small specialty in the UK and Ireland. There are about 40 Paediatric Urologists who are dedicated to looking after children. All Paediatric Urology Consultants in the UK have trained as either a Paediatric Surgeon or an Adult Urologist. They have then spent more time training to specialise and become Paediatric Urologists. (see below for more information on training)
In the UK Paediatric Urology is provided in a limited number of centres. All the centres also Provide Paediatric Surgery. Specialist Paediatric Urology services are located in the following cities:
Whilst some centres have Paediatric Surgeons who have an interest in Paediatric Urology (such as in Addenbrooke’s Hospital, Cambridge), some of the centres have dedicated Paediatric Urology services where the team concentrates solely on Paediatric Urology (such as in Birmingham Children’s Hospital).
Some centres provide what are referred to as supra-regional services. These are services which manage patients with certain conditions that came from outside their normal catchment area. For example, Manchester Children’s Hospital and Great Ormond Street Hospital are the only 2 centres in England which manage Bladder Exstrophy and Epispadias.
What training does a Paediatric Urologist Have?
Paediatric Urologists have sub specialised in Paediatric Urology. All UK consultants in Paediatric Urology have completed their training as either a Paedatric Surgeon or an Adult Urologist. They then spend further time training in Paediatric Urology. The majority of Paediatric Urologists have trained as Paediatric Surgeons.
The typical training that a UK medical school graduate has to go through in order to become a Paediatric Surgeon and then a paediatric urologist, may look something like this.
5 years Medical School
2 years Foundation Training
This is where the person has graduated as a doctor and is learning on the ward. They will work in a number of different specialties in this time. The specialities may include surgery, medicine, general practice. In their second year they may spend time in Paediatrics. All Foundation doctors are closely supervised. In order to progress in their training they need to prove that they have acquired a number of core skills and abilities.
2 Years Core Training
To get into Core Training, the doctor has to compete against other doctors. The Core Training Program lasts for 2 years. They will spend time in a number of surgical specialities. If they want to train in Paediatric surgery, they will need to complete at least 6 months in Paediatric Surgery. During this time the doctor has to:
- Gain a number of key skills and abilities in order to complete the Core Training Program
- Complete a number of courses
- Pass their Membership Exam for a Surgical College (e.g. Royal College of Surgeons of Edinburgh.)
During the second year of their Core Training, they can apply for a National Training Number (NTN) in Paediatric Surgery. In the UK there are around 10 - 15 training posts per year. Around 60 - 70 doctors apply for these posts. It is very rare for a doctor to be awarded an NTN as a Core Trainee. In most cases the doctor spends an additional 1 or 2 years gaining further experience in areas such as Paediatric Surgery, Neonatology or Paediatric Intensive Care.
Some Doctors spend between 1 - 3 years doing research during their training. The research time maybe taken at any time before the doctor becomes a consultant surgeon. Many surgeons continue to have a research interest when they become consultants.
6 Years - Higher Surgical Training
Whenever a doctor is awarded a National Training Number (NTN) they enter Higher Surgical Training. This lasts for a minimum of 6 years. This is where the doctor specialises in Paediatric Surgery. They are trained to perform investigations and operations. They also learn how to manage the conditions that they will be treating.
There are very strict guidelines about how they are trained. There are a number of operations that trainees must show they can do by the end of training. There are a number of other requirements that must be fulfilled in order to successfully complete their training. Once a trainee completes training, they will be awarded as Certificate of Completion of Training by the GMC. This allows the doctor to be added to the Specialist Register for Paediatric Surgery. The standards are overseen by a body called the Paediatric Surgery SAC (Specialist Advisory Committee) and the JCST (Joint Committee on Surgical Training) - a body that oversees the SAC.
NHS Consultants must be on the GMC’s Specialist Register for their speciality.
A Paediatric Surgical Trainee must successfully pass the Intercollegiate Exam in Paediatric Surgery in order to complete their training. This exam is taken in the last 2 years of their training. It tests their knowledge and ability to manage patients. The exam consists of 2 parts. The first part is a ‘written paper’ which test knowledge of Paediatric surgery. The second part is made up of a clinical exam and a viva exam. In the clinical exam, the candidate sees and exams patients. They ares tested on how they would manage them. For the viva, the candidates are questioned by experienced consultants. They can be questioned on any topic in the Paediatric Surgery Syllabus. The standard to pass this exam is high. This means that only people who are knowledgable enough to become a consultant pass it. If a trainee fails the exam too many times they may not be able to complete their training.
2 Years - Paediatric Urology Fellowship
To become a Paediatric Urologist, a Paediatric Surgeon needs to complete a 2 year dedicated Fellowship.
There are a number of nationally recognised fellowship posts in the UK (4 in London, 1 in Birmingham, 1 in Manchester, 1 in Nottingham, 1 in Leeds). Fellowships are awarded with competitive entry.
There are national training guidelines, which have been developed by British Association of Paediatric Urologists. The guidelines lay out the requirements for these fellowship posts. The fellows progress is reviewed yearly. This ensures they are getting adequate training.
After successfully completing a fellowship it is then possible to apply for a Consultant's post. It often takes around 18 - 20 years of training (including Medical School) to reach this point.
What happens after becoming a consultant?
Learning does not stop when a doctor becomes a consultant.
Most Paediatric Urologists spend time developing expertise in certain areas of Paediatric Urology - eg reconstructive urology, key hole surgery etc.
All consultants are appraised every year. This ensures that they are continuing to develop their practice. They are appraised by a peer in order to highlight any issues with outcomes.
Most consultants in the UK are members of British Association of Paediatric Urologists (BAPU). BAPU provides a forum for ongoing education, research and support. BAPU has an annual meeting in September every year and the majority of consultant Paediatric Urologists attend this meeting.
There are other meetings that the consultants may also attend such as:
- ESPU (European Society of Paediatric Urologists). This is main European research meeting each year.
- BAPS (British Association of Paediatric Surgeons).
Many paediatric urologists have a very busy NHS practice. They tend to have longer waiting lists than their Paediatric Surgical Colleagues. This can make it difficult to access a Paediatric Urology Service, and can be frustrating for patients.
Paediatric Urology is a specialty that looks after a wide range of conditions by specialists that have spent a long time training. It can be hard to know how to access a paediatric urologist and I will write an article about How to See a Paediatric Urologist in the near future.