Building on Knowledge for Urologic Management

Commentary From the Section on Urology

The Section on Urology (SOU) aims to promote evidence-based care and education for genitourinary conditions affecting the pediatric population. The SOU seeks to develop a collaborative relationship between pediatric urologists and members of the American Academy of Pediatrics (AAP) in conjunction with the American Urological Association and Societies for Pediatric Urology. In considering how urologic care has progressed over the last 75 years for pediatric patients, articles were reviewed for their academic and clinical impact. We highlight 3 landmark articles that profoundly affected urologic care in the pediatric population.

Building on Knowledge for Urologic Management

Julie W. Cheng, MD, MAE ¹, Laura B. Cornwell, MD², Christopher D. Jaeger, MD, MMSc³, Gina M. Lockwood, MD, MS, FAAP⁴

Affiliations: ¹Oregon Health and Science University, Doernbecher Children's Hospital, Portland, OR; ²University of Louisville School of Medicine, Norton Children’s Hospital, Louisville, KY; ³Boston Children’s Hospital, Boston, MA; ⁴University of Iowa, Department of Urology, Iowa City, IA

Highlighted Articles From Pediatrics

• Oppel WC, Harper PA, Rider RV. The age of attaining bladder control. Pediatrics. 1968;42(4):614-626
• International Reflux Study Committee. Medical versus surgical treatment of primary vesicoureteral reflux: report of the International Reflux Study Committee. Pediatrics. 1981;67(3):392-400
• Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999;103(3):686-693
• Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012;130(3):585-586

First Quarter Century (1948 to 1973)

Oppel WC, Harper PA, Rider RV. The age of attaining bladder control. Pediatrics. 1968;42(4):614-626

In the first quarter century, Oppel, Harper, and Rider carefully studied and reported the age of bladder continence in children. Despite its use of antiquated terms regarding race and ableism from that era, this study aimed to be representative of Baltimore children with respect to sex, race, and birth weight for a more comprehensive understanding of bladder control. Children were followed prospectively for 12 years to assess their daytime and nighttime continence. Through the reports of 859 boys and girls, this study provided insight into the prevalence of urinary continence and rates of relapse of incontinence in the first 2 years of life, at school age, and finally at 12 years of age. This study documented that the prevalence of bedwetting at 3-4 years of age was greater than widely believed and concluded that many children may not require remedial action at this age. Additionally, this study contributed to an understanding that bladder control may be related to sex and birth weight. Toilet training remains today a confusing time for families. The findings of this study that it is normal for children not to be completely continent by age 2 can help relieve social pressures faced by families as their children grow and develop.

Second Quarter Century (1973-1998)

International Reflux Study Committee. Medical versus surgical treatment of primary vesicoureteral reflux: report of the International Reflux Study Committee. Pediatrics. 1981;67(3):392-400

During the second quarter century, the International Reflux Study Committee published a report on primary vesicoureteral reflux (VUR) that summarized existing knowledge of VUR at a time when optimal management of the condition was uncertain and controversial. This report reviewed the current evidence regarding prevalence, pathogenesis related to renal scarring, potential interference with renal growth, and patient selection for medical and surgical management options. Subsequent studies have since contributed to an evolution in the understanding and management of this condition and to appropriate patient selection for treatment. Today, urologists have access to evidence-based guidelines for the diagnosis and management of this once highly controversial topic as published by the American Urological Association in 2010 and updated in 2017. Prophylaxis, healthy voiding habits, and constipation prevention remain the mainstays of medical treatment. Surgical intervention is now available using various techniques, including a minimally invasive option through robotic surgery.

Third Quarter Century (1998-Present)

Task Force on Circumcision. Circumcision policy statement. Pediatrics. 1999;103(3):686-693

Task Force on Circumcision. Circumcision policy statement. Pediatrics. 2012;130(3):585-586

Two high-profile statements focusing on circumcision appeared in Pediatrics in its third quarter century. Multidisciplinary task forces authored the 1999 policy statement and the 2012 update that comprehensively reviewed extant literature. The 1999 circumcision policy statement provided a background of penile development and anatomy and discussed issues affecting circumcised and uncircumcised children. The statement also reviewed issues related to balanitis, paraphimosis, phimosis, chronic inflammation, and adhesions for uncircumcised penises and described the procedure, appropriate analgesia, and the potential complications following circumcision. This paper presented the evidence that circumcision reduced the risk of urinary tract infections, sexually transmitted infections, and penile cancer but assessed these risks to be relatively small. This policy statement did not recommend routine circumcision and deferred the decision to parents and caregivers after informed discussions with healthcare providers.

An update to this policy statement in 2012 reviewed more recent evidence of the risks and benefits of circumcision that supported a higher benefit-to-risk ratio than had been appreciated in the 1999 statement. Although the choice to request a circumcision remains in the hands of parents and caregivers within the context of each family’s values and beliefs, this statement provided additional medical justification for the procedure that warranted third-party payment.