Hydronephrosis is a condition that affects about 1 in 100 babies, where urine accumulates or flows back into the kidney, causing its dilation. Babies with hydronephrosis can be diagnosed before birth (prenatal) or after birth (postnatal).

In many children diagnosed prenatally, the condition spontaneously resolves at birth or shortly thereafter. In children with mild or sometimes moderate hydronephrosis, kidney function is usually not affected, and the condition may regress over time after birth.

Hydronephrosis affects urine drainage in the urinary system, which consists of the kidneys, ureters, bladder, and urethra. When the urinary system is impaired, it can cause urine to flow back and the kidney to dilate. Hydronephrosis is usually caused by something blocking/obstructing urine flow or by urine reflux from the bladder to the kidneys.

Your doctor will describe your child's hydronephrosis as mild, moderate, or severe based on how much the kidney is stretched and how much urine flow is impaired and will say whether your child's hydronephrosis affects one kidney (unilateral) or both kidneys (bilateral). More than half of cases resolve spontaneously when the baby is born or soon after.

Most babies with hydronephrosis have no symptoms. Older children may also have no symptoms if they have mild or moderate hydronephrosis, and the condition may resolve on its own.

If your child has moderate to severe hydronephrosis, some symptoms may include:

- Abdominal pain
- Side pain (flank pain)
- Blood in urine (hematuria)

A child with hydronephrosis may develop a urinary tract infection (UTI). Symptoms of a urinary tract infection may include the following:

- Strong urge to urinate
- Pain while urinating
- Cloudy urine
- Back pain
- Fever
- Vomiting

If your child has had multiple UTIs over their lifetime, with or without fever, this may indicate some type of obstruction or reflux in the urinary system. However, UTIs can be difficult to detect in babies: in many cases, multiple unexplained fevers are the only sign.

Older children may have more recognizable UTI symptoms, including a strong urge to urinate, pain while urinating, or cloudy urine. If your child tends to have repeated UTIs, they should be evaluated for possible urinary tract obstruction.

In hypospadias, a boy's urethral opening (through which urine and semen pass) is located on the underside of the penis instead of the tip. This condition, present at birth, affects about 1 in 100 boys. Although very mild forms of hypospadias may not interfere with urinary or reproductive function, most boys with the condition require surgery. The outlook for babies undergoing this surgery is extremely good: in most cases, they fully recover and have a normal-looking and fully functional penis within about six months.

In hypospadias, the urethral opening may be located anywhere along the underside of the penis. The location of the opening determines the severity of the condition. In anterior or distal hypospadias, the urethral opening is near the tip of the penis. This is the mildest form of hypospadias, occurring in about 50% of cases. Middle hypospadias means the opening is in the middle of the penis and accounts for about 30% of cases. In the most severe form of the condition, known as posterior or proximal hypospadias, the opening develops in the boy's scrotum and perineum and occurs in 20% of cases.

Other signs of hypospadias include:

- Downward urine spray (in older boys with more severe hypospadias, this may mean they have to sit to urinate)
- Ventral curvature of the penis, called chordee
- "Hooded" appearance of the penis, caused by extra foreskin along the top
- Abnormal appearance of the tip of the penis (the glans)
- In some cases, boys born with hypospadias may also have undescended testicles, inguinal hernias, or both.

Hypospadias does not cause physical pain or block urination, but if left untreated, more severe forms may interfere with sexual function in adulthood.

Hypospadias is a congenital condition, meaning it occurs while the baby develops in the mother's womb. As the fetus develops, the tissue on the underside of the penis that forms the urethra does not fully close, shortening the passage. In many cases, the foreskin the fold of skin covering the tip of the penis, or glans also does not develop properly, resulting in extra foreskin on the dorsal part of the penis.

Professor Tiago Rosito has extensive experience in caring for boys with hypospadias, especially in its more severe presentations, using the latest surgical techniques.

A urinary tract infection (UTI) is a bacterial infection of the urinary tract that can cause discomfort and complications for your child if not properly treated. There are several types of UTIs:

- Urethritis - an infection of the urethra
- Cystitis - a bacterial infection in the bladder that often ascends from the urethra
- Pyelonephritis - a kidney urinary infection that usually results from an infection that has spread through the tract or a blockage in the urinary tract

Facts about UTIs in children

- UTIs are not very common in children who are not yet potty-trained, so if your baby has one, further tests are important.
- UTIs are more common in girls because they have a shorter urethra.
- Uncircumcised boys are more likely to develop a UTI than circumcised boys.
- Children with total or partial urinary tract blockages are more likely to develop a UTI.

Nocturnal enuresis is the medical term for involuntarily urinating during sleep. Other words for this condition include incontinence, urination problems, or urinary accidents. Most children gain bladder control by age 4 for daytime control and by age 6 for nighttime control, but up to 20% of first-grade boys (6 to 7 years old) and 17% of first-grade girls have issues with nighttime urine leakage.

There is no single cause for daytime or nighttime bedwetting, but we believe that certain factors, such as bladder capacity and genetics, may play a role. Other reasons include:

- Small functional bladder capacity
- Difficulty waking up from sleep or the presence of a sleep disorder
- A problem with the proper functioning of hormones that help regulate urine volume
- Genetics (enuresis tends to run in families)
- Delay in your child's ability to hold urine (this can be a factor up to about 5 years old)
- Constipation, which is an accumulation of stool in your child's intestines that can press on the bladder and cause accidental urination
- The child being too busy to stop and completely empty the bladder or may not notice that the bladder is full

Other medical conditions may also be causing enuresis in your child:

- Recurrent urinary tract infection (UTI)
- Diabetes
- Sickle cell anemia

Depending on the type and severity of enuresis, possible treatments include nighttime alarms to wake the child up to go to the bathroom, medications, bladder training, and positive reinforcement.

A visit to a doctor specializing in enuresis treatment can help identify the best treatment option for your child. Identifying the problem early can help reduce the stress and emotional discomfort a child may feel from urine accidents.

Facts about enuresis

- Affects 10 to 20 percent of boys aged 6 to 7.
- Affects 8 to 17 percent of girls aged 6 to 7.
- Among children with enuresis, 74% urinate at night, 10% during the day, and 16% both.
- About 15% of all 5-year-old children wet the bed at night.
- About 7% of 8-year-old children wet the bed at night.

Enuresis resolves on its own in 15% of children each year. So, the older your child gets - even if you choose not to pursue any treatment - the more likely they are to stay dry. However, children who have urination issues due to an underlying medical problem may require longer-term treatment and care.

The most common causes of urinary incontinence in children are Nocturnal Enuresis and voiding dysfunctions.

Each child is different. Some of the symptoms of a urinary tract infection (UTI) that your child may experience include the following:

Babies

- fever
- abdominal pain
- colic
- abdominal fullness
- foul-smelling urine
- poor growth
- weight loss or failure to gain weight
- irritability
- vomiting
- poor feeding
- diarrhea

Older children

- urgency to urinate
- daytime and/or nighttime incontinence
- frequent urination
- pain or difficulty urinating
- discomfort above the pubic bone
- blood in urine
- foul-smelling urine
- nausea and/or vomiting
- fever
- chills
- back or side pain below the ribs
- fatigue
- small amount of urine during urination despite urgency

A urinary tract infection (UTI) occurs when microorganisms, usually bacteria from the digestive tract, cling to the opening of the urethra, the hollow tube that carries urine from the bladder to the outside of the body, and enter the bladder, where they begin to multiply. Most infections arise from the Escherichia coli (E. coli) bacteria, which is normally found in everyone's intestines.

We will work with you to relieve your child's discomfort and find a solution for the infection and any resulting complications. Our specialists diagnose, treat, and care for babies, children, and adolescents with problems affecting the urinary tract, bladder, and kidneys.

Some children, during their embryonic development, present alterations in the formation of external genitalia (penis, testicles, vulva, clitoris, vagina, etc.), preventing the immediate identification of their gender. In these cases, a careful approach in conjunction with an endocrinologist is necessary for the final definition. After the definitive diagnosis, surgical adjustment of the external genitalia to the definitive gender is often necessary.

Our multidisciplinary team is prepared to assist in this journey, from the antenatal period (pregnancy) to the final surgical correction in childhood and adolescence.

Although kidney stones are still relatively uncommon in children, the number of cases is growing alarmingly. Kidney stones are small, hard deposits of minerals and acids formed in the urinary tract, which can obstruct urine drainage and cause intense pain; some children may experience nausea and vomiting. There are many different types of stones, with calcium oxalate and calcium phosphate stones being the most common. There are other less common types of kidney stones.

Most of the time, stones are found in the kidney or ureter (the tube that connects the kidney to the bladder). Many stones pass on their own without treatment; others will need to be removed, which can usually be done using a non-invasive method.

Kidney stones form when there are too many stone-forming minerals and not enough water in the urine. This can happen because there is an abnormally high content of minerals in the urine or because the urine is too concentrated due to dehydration.

Some rare diseases associated with kidney stones may result from innate metabolic problems, meaning that the child has a genetic condition that causes their body to produce these stones. A family history of kidney stones predisposes other family members to develop stones, although it is not well understood how these tendencies are passed from one generation to the next.

Children who are unable to move for long periods (such as immobilization after surgeries) may also be susceptible to stones because when bones are inactive, they are unable to regenerate properly, resulting in the release of calcium into the system.

PROURO KIDS and Professor Tiago Rosito created a Pediatric Kidney Stone Program because more and more children are developing kidney stones. We see children who have had kidney stones and those who are at risk of developing them.

Your child will see a pediatric urologist (Professor Rosito) and a pediatric nephrologist in the same appointment (with prior notice that it is a kidney stone consultation). This multidisciplinary approach allows direct collaboration between the two specialists to optimize your child's care and work together to develop a treatment plan - in real time.

We can treat stones in various ways, depending on the size, location, number, and composition of the stones. In almost all children, we can treat these stones with non-invasive or minimally invasive surgical techniques using the latest endourology techniques; in rare cases, we may use robotic surgery techniques to remove the stones.

The best treatment is prevention. Your child will receive a metabolic evaluation to determine if they have risk factors for future kidney stones. Then, we prescribe individualized treatment plans to prevent new stones from forming and monitor your child with urine and blood tests and, sometimes, ultrasound exams.

Spina bifida - a term that means "split spine" - is a condition that occurs when the brain, spinal cord, or the membranes covering them (meninges) do not fully develop. It is the most common neural tube defect in Brazil.

The symptoms of spina bifida vary widely depending on the type of spina bifida the child has. Many children with spina bifida have no symptoms or only mild symptoms. This may include:

- A small tuft of hair, a dimple, or a birthmark on the spine
- Chronic constipation without another cause
- Chronic urinary or bowel incontinence without another cause
- Chronic urinary tract infections
- Leg or back pain
- Children who do not walk properly
- Foot drop
- Scoliosis

Other children present symptoms that are noticeable at birth, such as an opening in the spine or a sac protruding from the spine, often diagnosed during the antenatal period.

A common concern for parents whose children have been diagnosed with neurogenic bladder dysfunction is the question: "Will my child still be wearing diapers when they reach school age?"

The short answer is: probably not. While it is impossible to say that your child will never have an accident, a neurogenic bladder can be treated with medication, bladder catheterization, and/or routine check-ups with their doctors, ensuring that your child has as normal a life as possible.

Here is what you need to know about neurogenic bladder:

- Neurogenic bladder is a urinary tract dysfunction in which the bladder does not empty properly due to a neurological condition or spinal cord injury.

- The condition can be caused by a birth defect, usually involving the spinal cord, or it can be acquired as a result of another problem.

- While neurogenic bladder cannot necessarily be cured, it can definitely be managed.

- Most cases of neurogenic bladder can be treated with medication and intermittent catheterization.

- A minority of children with the condition require major reconstructive surgery.

As one of the country's leading pediatric urology specialists, he has extensive experience in treating children with neurogenic bladder dysfunction, from prenatal evaluation and counseling to follow-up care for children, adolescents, and adults with the condition.

The reality is that neurogenic bladder dysfunction is almost always part of a larger problem; it rarely, if ever, occurs on its own. It is a common complication of spina bifida (myelodysplasia), a condition in which there is abnormal development of the spinal cord. It can also be a complication of spinal cord trauma, central nervous system tumors, and pelvic tumors. We take a multidisciplinary approach to diagnosing and treating your child's neurogenic bladder, seeking care from doctors and nurses across various specialties (neurology, neurosurgery, nephrology, pediatrics, pediatric surgery, among others).

In a normal urinary system, urine flows from the kidney through the ureter to the bladder. In children with ureteropelvic junction (UPJ) obstruction, there is a blockage between the ureter and the kidney that can slow or block urine flow. In severe cases, urine cannot drain from the kidneys, potentially enlarging the organ and causing permanent damage. Important facts:

- A UPJ obstruction occurs when a blockage between your child's kidney and ureter prevents urine flow.
- UPJ obstructions are not very common, occurring in approximately 1 in 1,500 babies.
- Many of these blockages are small enough not to damage your child's kidney.
- Severe blockages can impair the kidney's ability to drain urine, which can lead to permanent kidney damage.
- If your child's UPJ obstruction is severe enough to put their kidney at risk, a single surgical procedure can be performed to remove the blockage.

Mild: Most babies do not show any symptoms. If your child's UPJ obstruction was observed on a prenatal ultrasound, it is likely because they have hydronephrosis (kidney dilation). This is a fairly common condition that often resolves on its own after birth.

Moderate to severe: More severe UPJ obstructions may be associated with blood in the urine or abdominal pain in older children.

Severe pain on your child's side is also a possibility, especially after being hit during a contact sport or an accident.

If a significant UPJ obstruction has caused urine to accumulate in your child's kidney, they may also exhibit some or all symptoms of kidney failure:

- hemorrhage (severe bleeding)
- fever
- skin irritation
- bloody diarrhea
- severe vomiting
- abdominal pain
- no urine output or excessive urine output
- pale skin
- edema (swelling)
- swelling around the eye
- detectable abdominal mass

The exact cause of UPJ obstructions is not known, but they are congenital (present at birth) and are often discovered during routine prenatal ultrasound, suggesting that they arise from problems in the development of your baby's urinary tract. There are a few ways in which an obstruction can form while your baby is developing:

- A part of your baby's ureter does not fully develop, leading to a narrow portion that can be easily blocked.
- There may be part of the muscle in the ureter wall that does not contract properly.
- Your baby may have what is called an "abnormal vessel," meaning there is an extra artery feeding the kidney. In this situation, this secondary artery can cause twisting or blocking of the ureter.
- The condition is known to run in families, indicating a genetic component, although specific genes have not yet been identified.

If a UPJ obstruction is detected early, it can be treated quite easily. If not treated or misdiagnosed, however, chronic urine obstruction in the kidneys can cause permanent damage to your baby's kidneys and urinary system. This is why it is vital to consult a urology specialist for an accurate and timely diagnosis.

Each child is unique, and your child's long-term health depends on their exact condition. But the key point is that with an accurate diagnosis, appropriate treatment, and strict management of your child's care, they can at least reach definitive renal development.

A benefit of being followed by Prof. Tiago Rosito is the network of connections that facilitates all Maternal-Fetal Care, with consultations from various specialties associated with fetal care. If your baby is diagnosed before birth with a UPJ obstruction or any hydronephrosis, our multidisciplinary team will closely monitor the condition from pregnancy until birth and beyond.

If your child's doctor determines that they need surgery, you will meet with Prof. Tiago Rosito and work together to develop a treatment plan that fits your child and their condition. 

Prof. Tiago Rosito pioneered the use of robotic surgery for complex procedures through small incisions, reducing pain, recovery time, and hospital stay. Today, we perform surgeries with all available technologies to correct your child's congenital abnormalities, including laparoscopy, robotics, and endourology.

Circumcision is a surgical procedure to remove the skin that covers the tip of the penis, called the foreskin. In many cultures, circumcision is a religious rite or a ceremonial tradition. It is most common in Jewish and Islamic religions. In the United States, neonatal circumcision is an elective procedure. Medically, its primary indication is phimosis, which is characterized by the inability to expose the glans due to a narrow and non-distensible foreskin. Phimosis is considered physiological (natural/expected) until at least five years of age when, in principle, it should resolve spontaneously in 90% of boys. Other indications for postectomy include urinary tract infections and balanitis (infections of the foreskin).

Circumcising your child for religious or social reasons is a deeply personal choice, and deciding whether it is right for your family will require consideration of many factors. In addition to the personal, cultural, and religious aspects associated with the decision, you may also have medical questions.

Religious/cultural circumcision can be performed at any age. Traditionally, the most common time to do this is right after birth or within the first month of life. Since the process is painful, a local anesthetic is used to numb the area, and the surgery is performed while the baby is still awake. If the baby is older, we recommend anesthesia to reduce pain and the risk of injury to the penis. As children get older, they become more aware of their sexual organs, so there are more psychological impacts associated with the surgery, and children may become scared.

Medical circumcision is indicated after five years of age in physiological phimosis after at least one cycle of topical treatment (creams and ointments) without success, or before this age when associated with infections or difficulties urinating.

If your baby is circumcised, the penis will be easier to clean for parents (and ultimately for the child), which helps reduce the risk of bacterial infection. Other potential benefits include:

- Near elimination of the lifetime risk of penile cancer in adulthood
- More than 90 percent reduction in the risk of urinary tract infections (UTIs) during infancy.
- Reduced incidence of balanitis, an infection of the glands or head of the penis, and posthitis, an infection of the foreskin (the skin covering the head of the penis)
- Elimination of phimosis (inability to retract the foreskin)
- Most researchers generally agree that circumcised men are less likely to acquire and transmit HIV and some sexually transmitted diseases. However, if your child is not circumcised, he can do well by learning to fully retract the foreskin during toilet training and taking care to keep the entire penis clean with water and soap every day.

Circumcision is quite common. The Centers for Disease Control and Prevention recently reviewed current trends in neonatal circumcision in the United States, and the national rate was approximately 60 percent in the United States.

Circumcision can be performed at any age. Traditionally, the most common time to do it is right after the baby is born or within the first month of life. When performed as a treatment for phimosis, it is usually done from the age of five or earlier if there are infections.

The boy is comforted, given a mild sedative in the preparation room, and then taken to the operating room accompanied by one of the parents. He may receive a local anesthetic (anesthetic medication) to reduce discomfort. The skin covering the tip of the penis is removed with a protective device, and then a gauze with Vaseline or antibiotic ointment is applied. In older children and adults, the procedure is commonly performed under general anesthesia.

Despite what many people may believe, this is not an extremely painful procedure. If local anesthesia is administered, the child will feel pressure and movement but not pain. The child may be briefly upset while being held in place.

Newborns and infants recover very quickly from the procedure, usually within 12 to 24 hours. Young children recover in 1 to 2 days. Older children and young adults recover in 3 to 4 days. After circumcision, there may be temporary bruising or mild swelling that can last for several weeks.

Undescended testicles, also known as cryptorchidism, are a fairly common and usually painless congenital condition in which one or both of the baby's testicles (testes) have not moved into the proper position. One to 2 percent of male babies are affected.

Before a boy is born, the testicles form in the child's abdomen. During the third trimester, the testicles travel from the abdomen, down through the groin, and into the scrotum (the sac of skin under the penis). An undescended testicle does not complete the descent process. The testicle may be located anywhere from the abdomen to the groin and may affect one or both testicles.
Premature babies are affected by undescended testicles at a higher rate. The more premature your baby is, the greater the chance of having an undescended testicle.

In some cases—about 20 percent of affected boys—an undescended testicle descends on its own during the first six months of the child's life, not requiring surgery.

Parents of boys who have been diagnosed with undescended testicles often worry: "Will my son be able to have his own children?" Fortunately, for boys with one undescended testicle, the answer is "yes" in most cases.

In a baby affected by undescended testicles, one or both testicles appear to be missing or cannot be felt in the scrotum. If both testicles have not descended, the scrotum will be abnormally small and flat. If only one testicle is affected, the scrotum may appear crooked. If your baby's testicle seems to be "sometimes there and sometimes not," we call this a retractile testicle. It is a normal condition that does not require treatment in most cases.

Experts have not yet identified a single cause of undescended testicles. The following factors may interfere with the normal descent and development of the testicles:

- abnormal anatomy
- hormonal problems
- environmental influences

Undescended testicles can increase the risk of infertility. Normally, when the testicles are in the scrotum, they are about three to five degrees cooler than they would be if they remained inside the abdominal cavity. The higher temperatures inside the body can impair testicular development and may affect the production of healthy sperm when the boy is older.

Boys born with undescended testicles are also slightly more likely to develop testicular cancer, even after corrective surgery. The advantage of surgery, however, is that it moves the testicles to a location that allows for routine self-examination, which can lead to early detection of any abnormalities later in life.

Rarely, undescended testicles at birth will spontaneously migrate to the scrotal sac; all others must be corrected surgically. Ideally, this surgery should be performed by the end of the first year of life.

If you have any doubts regarding the proper positioning of your child's testicles, seek care from Professor Tiago Rosito. Prof. Rosito uses laparoscopy - a minimally invasive surgical procedure that involves looking into the abdomen through small incisions and using operating tools, cameras, and highly sensitive miniaturized telescopes. He also uses laparoscopy to move intra-abdominal testicles into the scrotum. This allows for the optimal positioning of the testicles in the scrotum.

A hydrocele is caused by fluid in the sac that normally surrounds the testicle. It often appears as a painless swelling in the scrotum (the pouch containing the testicle). Hydroceles are commonly found in newborn boys, especially in premature babies.

Most hydroceles in male newborns will improve on their own as the channel decreases. Those that do not improve on their own may require surgical correction, as they are caused by the persistence of a channel connecting the abdomen to the scrotum (called a communicating hydrocele), allowing abdominal fluid to drain into the scrotum. Hydroceles can also occur in older boys during puberty or in adulthood.
Hydroceles that occur in boys during puberty (or pubertal development) are adult-type hydroceles. They typically do not have any channel connecting the abdomen to the scrotum but simply represent overproduction of fluid by the tissue around the testicle. If they become large, surgical correction may be needed. It is important that this type of hydrocele be evaluated, as it can occasionally be an early sign of testicular tumor.

When a boy has a non-communicating hydrocele, there is no connection between the abdominal cavity and the sac around the testicle in the scrotum. This type of hydrocele is often found in newborns and often disappears or resolves over time. It may take up to a year for this to happen, but as long as the swelling is decreasing, it can be safely observed.

If your child is older and has this type of hydrocele, it is called an "adult-type" hydrocele. They can be produced by other problems, such as infection, torsion (twisting of the testicles), or tumor; therefore, examination by a doctor is essential if swelling occurs in the scrotum of an older child or teenager.

When the passage between the abdomen and the scrotal sac does not close, the hydrocele is called communicating or open. This means that the fluid around the testicle can flow back into the abdomen. You may notice that the hydrocele appears smaller in the morning and larger at night. This may be due to your child standing all day. It may also appear smaller when your child's doctor presses on the scrotum, as the pressure can cause the fluid to return to the abdomen.

During the seventh month of fetal development, the testicles move from the abdomen to the scrotum. When the testicle descends, it brings with it the lining of the abdominal cavity in the form of a sac (processus vaginalis). The sac allows fluid present in the abdomen to surround the testicle. This sac usually closes before birth, preventing additional fluid from going from the abdomen to the scrotum, and the fluid is absorbed.

Hydroceles do not harm the testicles in any way and do not cause pain to your child. Sometimes, however, if the sac remains open, a loop of the intestine may be pushed through the opening, creating a hernia. If your child's scrotum suddenly appears very large and hard and he does not stop crying, seek care immediately. Your child may need immediate attention.

Micropenis is an extremely rare genital development malformation associated with hormonal and genetic alterations. The vast majority of boys and men who believe they have a small penis are within the normal spectrum. If you have doubts about the correct genital development of your child, Professor Tiago Rosito is the ideal professional to perform this evaluation.

A hernia is present when there is an opening in the abdominal wall through which a sac protrudes from the abdominal cavity through the abdominal wall. In pediatric patients, it is usually a congenital anomaly and not something that develops after birth.

In adults, it can occur due to progressive weakness of the abdominal wall, but it rarely occurs in babies, children, or adolescents. The hernia will be apparent if there is a soft bulge in the inguinal area (the fold between the abdomen and the upper leg) or in the scrotum.

A hernia that occurs in the groin area is called the inguinal region. Part of the abdominal contents, such as intestines, can be pushed through this opening. Inguinal hernias occur in 2% of all children but are more common in boys than in girls. They can occur on either side but are more frequent on the right side.

The testicles develop in boys in the back of the abdomen, just below the kidney. During fetal development, the testicle descends from this location into the scrotum, pulling a sac-like extension of the lining of the abdomen (inguinal hernia into the scrotum). This sac surrounds the testicle in adulthood, but the connection to the abdomen usually resolves completely. If this does not occur, a hernia will occur with the sac extending from the abdomen through the abdominal wall and into the inguinal canal (inguinal hernia in the canal), where it ends in the groin or may persist going into the scrotum and the sac surrounding the testicle.

Inguinal hernias are only apparent when there is content from the abdominal cavity within the sac. In babies and children, the sac may not be apparent if the contents of the abdominal cavity have not escaped from the abdomen into the sac because the opening in the abdominal wall is too narrow to allow this to occur.

With development, the abdominal wall becomes stronger and may push the contents through the opening into the sac, often dilating this opening. Some factors put children at higher risk of inguinal hernias, such as:

- prematurity
- undescended testicles
- a family history of hernias
- cystic fibrosis
- developmental dysplasia of the hip
- urethral abnormalities

Although girls do not have testicles, they have an inguinal canal, so they can also develop hernias. Often, it is the fallopian tube and ovary that fall into the hernial sac.
Occasionally, in boys and girls, the loop of intestine that protrudes through a hernia may become trapped and cannot return to the abdominal cavity. If the intestinal loop cannot be gently pushed back into the abdominal cavity, this section of the intestine may lose its blood supply. A good blood supply is necessary for the intestine to be healthy and function properly.

Inguinal hernias appear as a bulge or swelling in the groin or scrotum. The swelling may be more noticeable when the baby cries and may decrease or disappear when the baby relaxes. If your doctor gently pushes this bulge when the child is calm and lying down, it will usually get smaller as the contents of the sac return to the abdomen.

If the hernia is not reducible, the loop of intestine may be too swollen to return through the opening in the abdominal wall and may require urgent surgery.

Testicular torsion is a twisting of the spermatic cord that cuts off the blood supply to the testicle. It is a rare condition that can destroy a testicle in just four to six hours. Each testicle is connected to the internal reproductive organs by the spermatic cord, a structure that contains blood vessels, nerves, muscles, and a tube to transport semen. If this cord twists, the blood supply to the testicle is cut off. Without blood, the testicle cells will die.

- If your child has been diagnosed with testicular torsion, emergency surgery should be performed immediately.
- Testicular torsion can occur in both newborns and adolescents.
- It is a rare condition that can destroy a testicle.
- If you suspect your child has testicular torsion, seek emergency medical care immediately.

When a child has testicular torsion, they may have a swollen, red, and tender scrotum. Older boys and young men who develop torsion may have symptoms such as:

- testicular pain
- abdominal pain
- nausea
- vomiting
- Half of the time, boys who have had testicular torsion have had previous episodes of testicular pain.

In general, testicular torsion is responsible for about 40% of all cases of acute scrotal pain and swelling. It usually occurs during two periods of time at birth and during puberty, but can occur at any age. Many boys and men who develop testicular torsion have an anatomical abnormality that causes the spermatic cord to twist more freely.

Newborn torsion, which accounts for 12 percent of all cases of testicular torsion, is usually discovered after the development of a swollen, red, and enlarged scrotum. If this occurs before birth, the testicle is most likely unsalvageable, but torsion that occurs in the weeks after birth can potentially be untwisted if discovered in time.

Paraphimosis is an urgent condition where the foreskin is retracted to expose the glans and, due to its narrowing, cannot cover the glans again. Symptoms include foreskin edema and significant pain in the constricted area. It can happen at any age, but the diagnosis is often delayed in adolescence due to the boys embarrassment in seeking help. In extreme cases, it can lead to penile injury.

It should be urgently evaluated as there is a risk of requiring surgical intervention.

Voiding dysfunction means that your child cannot completely empty their bladder.

In a normal cycle, your child's bladder stretches easily as it fills with urine and then contracts completely during urination. There should be no premature bladder contractions or increased pressure as it fills.

During the normal urination phase, there should be complete relaxation of the external urethral sphincter muscle, so that the urine released from the bladder flows smoothly and completely, without interruption, as the bladder empties. An interrupted or intermittent flow of urine or incomplete emptying are causes of voiding dysfunction.

Many children, after leaving diapers, develop uncoordinated urination habits, with difficulties in filling and emptying. Symptoms typically include urinary incontinence, urinary tract infections, postponement (holding urine until they can no longer hold it), urinary urgency (having to run to the bathroom), and pollakiuria (going to the bathroom countless times without relief).

Treatment is generally behavioral, aiming to modify urinary habits and retraining. This management is done by Prof. Tiago Rosito and his multidisciplinary team composed of a nurse and physiotherapist.

Some genetic alterations such as Rokitansky Syndrome result in the absence of the vagina (vaginal agenesis). This finding is generally discovered in adolescence due to the absence of menstruation.

Vaginal reconstruction should be done at this age through numerous dilation and surgical techniques. Professor Tiago Rosito has extensive experience and performs vaginoplasties using various techniques. In general, we use free skin grafts, a technique developed by the Urology team at Hospital de Clínicas de Porto Alegre.

Megaureter is the medical term for a dilated ureter. The ureter is a tube-like structure through which urine passes on its way from the kidney to the bladder. Each person has two ureters, one for each kidney. Together, the ureter and the kidney's collecting system are called the upper urinary tract.

Boys are more likely than girls to have a megaureter. The condition often has no symptoms and, in infants, may resolve on its own. In older children, megaureter can cause urinary tract infections (UTIs). In some cases, it can cause severe kidney damage.

There is a good chance that your child will not show symptoms of megaureter. Often, the condition is detected on prenatal ultrasound. However, some children exhibit one or more of the following symptoms during early childhood:

- abdominal mass that can be seen or felt
- back or abdominal pain
- urinary tract infection with fever
- hematuria (blood in the urine)
- urinary incontinence
- urolithiasis (formation of stones in the urinary tract)

There may be different causes for megaureter. Normally, the ureter is made of flexible muscle tissue. Some children are born with stiff and inflexible tissue in the lower part of one or both ureters. Without flexible tissue in this location, the movement of urine to the bladder is more difficult. Instead, urine refluxes into the ureter and causes it to dilate.

In other children, megaureter is caused by problems with urination. Some of the urine that should flow from the kidney to the bladder travels back up the ureter toward the kidney. This is called vesicoureteral reflux and is often potentially serious.

Although it often has a benign course, all ureteral dilations should be evaluated by a pediatric urologist.

In children with a duplicated collecting system, also known as ureteral duplication, one kidney has two ureters (tubes that carry urine from the kidney to the bladder) instead of one. Children with this condition often also have a ureterocele, a swelling of the part of the ureter closest to the bladder due to the opening of the ureter being too small. This obstructs the flow of urine to the bladder, causing urine to back up into the ureter toward the kidney.

In a duplicated collecting system, the ureter with the ureterocele usually drains the upper half of the kidney, while the other ureter drains the lower half. The ureter with the ureterocele may enter the bladder lower than the other ureter, which can cause a reflux of urine (reflux) into the upper ureter. A duplicated collecting system can result in frequent urinary tract infections, reflux of urine into the kidneys, and sometimes kidney damage.

Ureteral duplication is much more common in girls than in boys. No one knows the cause of ureteral duplication; however, some cases have been reported in siblings, suggesting a genetic component.

- back pain
- urinary tract infection

A duplex collecting system and ureterocele are usually treated together. The treatment of the ureterocele usually depends on the size of the constriction and the function of the kidney drained by the ureter.

Vesicoureteral reflux (VUR) is the result of abnormal formation of the valve between the ureter and the bladder. This valve ensures that urine travels from the kidney to the bladder. If your child has VUR, urine flows back into the ureters and kidneys. Some children have only mild VUR, while others have large amounts of urine refluxing into the kidneys. Although VUR itself is not usually painful, VUR can become a problem if the child develops a urinary tract infection (UTI) in the bladder. With this type of infection, bacteria are carried back from the bladder to the kidneys, and this can result in a severe infection and possibly kidney damage.

VUR is a condition that affects about 1 to 3 percent of all children. However, there are certain groups of children in whom VUR is much more common, including:

- Children with hydronephrosis: in this group, VUR is observed in about 15 percent of these children when testing is done after the baby is born.
- Children with urinary tract infections, especially if the infection is associated with fever. In this group, VUR is found in 50 to 70 percent of these children.

Children with vesicoureteral reflux (VUR) may not feel ill because VUR usually has no symptoms. VUR is most often diagnosed after a child has had a urinary tract infection (UTI) accompanied by fever. Some children are also diagnosed shortly after birth if they had hydronephrosis (kidney dilation) on their prenatal ultrasounds (before birth).

Common symptoms of UTI in children include:

- fever
- pain or burning during urination
- strong or foul-smelling urine
- sudden onset of frequent urination or urination accidents
- abdominal or flank pain (between the hip and ribs)
- poor growth and development of the baby

The cause of VUR is unknown, but there is a strong genetic component, although no specific gene has been identified. VUR is common among children and siblings of parents with VUR. During infancy, VUR is more frequent in boys. In older children, VUR is diagnosed more frequently in girls.

VUR can also occur as a result of these less common problems:

- abnormal bladder function due to nerve or spinal cord problems, such as spina bifida
- urinary tract abnormalities, such as posterior urethral valves, bladder exstrophy, ureterocele, or ureteral duplication
- dysfunctional voiding (bladder and bowel problems, including accidents, frequent urination, or constipation)

Prof. Tiago Rosito and his team adopt a conservative approach to VUR. Most children outgrow VUR on their own, and we give them the chance to do just that. Our primary goal is to treat vesicoureteral reflux (VUR) and prevent infections that can affect the kidneys and possibly cause kidney damage. Our specialists offer a comprehensive approach to the management of vesicoureteral reflux, from initial diagnosis to treatment and follow-up.

In cases where surgical intervention is necessary, we use techniques with varying degrees of invasiveness, from endoscopic injections with Deflux and Vantris to open and robotic reimplants.

Bladder exstrophy is a complex and rare congenital defect involving the urinary, reproductive, and intestinal tracts, as well as the musculoskeletal system. During a baby's development in the womb, the abdominal wall and underlying organs sometimes do not fuse properly, and the baby is born with the bladder inside out and exposed outside the body.

Bladder exstrophy usually involves several systems within the body, including:

- the urinary tract
- the reproductive tract (external genitalia)
- pelvic skeletal muscles and bones

Rarely, the intestinal tract is involved, requiring the participation of a pediatric colorectal surgeon.

Bladder exstrophy can result in weakened abdominal muscles and a shorter urethra and vagina or penis than average. It can present several associated challenges during care, including:

- reduced bladder growth
- urinary incontinence (enuresis)
- urinary tract infection
- vesicoureteral reflux
- epispadias

Children with bladder exstrophy also have epispadias. Epispadias occurs when the urethra does not close normally, and the inner lining of the urethra is flat and exposed on the upper surface of the penis in boys and between the clitoris in girls. In some cases, epispadias may be present alone.

In isolated epispadias, the bladder is closed and covered by the muscles of the lower abdominal wall and skin. In some children with epispadias, there may be pelvic bone abnormalities similar to, but not as severe as, those seen in bladder exstrophy.

The cause of bladder exstrophy and epispadias is unknown. Popular theories suggest that a normal structure known as the cloacal membrane may overdevelop in these babies. This may prevent proper tissue development, internal growth, and fusion of the supporting structure of the lower abdominal wall. Some studies show clustering of the condition in families, suggesting an inherited factor. However, the chance of parents having another child with bladder exstrophy is less than one percent.

Follow-up and care for the family and baby are carried out from the antenatal period. Multidisciplinary management with urologists, orthopedists, pediatricians, nephrologists, nursing, physiotherapy, and others is important. There is no urgency in the surgical management of these patients. Professor Tiago Rosito uses the inguinal flap technique for bladder coverage as proposed by Prof. Giron (the largest Brazilian experience) and usually performs the surgery in stages (first closing the bladder, then the epispadias, and finally continence) as in the main global centers. Using these techniques, osteotomies are not necessary, and rarely is hospitalization in intensive care units required for more than 24 hours.

Prof. Rosito, being a urologist by training, follows newborns and also has extensive experience in following these patients through adolescence and into adulthood.

Urological tumors are tumors that occur in a child's urinary tract. There are many different types of urological tumors, which can be benign (non-cancerous) or malignant (cancerous). This can include:

- testicular tumors
- kidney tumors
- bladder tumors
- prostate tumors
- vaginal tumors

We approach urological tumors as a team, working together with our colleagues in oncology, radiotherapy, general surgery, and other specialties.

Depending on your child's individual situation and the specific type of tumor, we may use minimally invasive approaches to remove the tumor, which can result in a quicker recovery and less pain and scarring for your child. For certain types of tumors, such as those of the testicle, prostate, and bladder, we may use nerve-sparing techniques that help preserve organ function. For eligible patients, we offer fertility preservation services and telemedicine follow-up consultations.

Urethral valves occur when a boy is born with extra flaps of tissue that have grown inside his urethra, the tube through which urine exits the urinary tract. This extra tissue prevents urine from draining properly from the bladder to the tip of the penis and out of the body. When urine cannot normally be expelled from the body, the organs of the urinary tract (kidneys, ureters, bladder, and urethra) can become dilated or swollen. If this dilation occurs, it can cause serious damage to the tissues and cells of these organs. Posterior urethral valves are the leading urological cause of chronic renal failure, dialysis, and pediatric kidney transplantation.

The two main types of urethral valves are posterior urethral valves and anterior urethral valves. Of the two, posterior urethral valves are much more common than anterior urethral valves. The severity of these disorders depends on the degree of urethral obstruction. The symptoms and care for anterior urethral valves are similar to those for posterior urethral valves.

In mild cases of urethral valves, a boy's symptoms may not come to light until the age of 10 or older. In more severe circumstances, they may present as hydronephrosis (severe kidney dilation) in newborns. Symptoms of urethral valves can vary from child to child and may include:

- an enlarged bladder, which can be detected through the abdomen as a large mass
- urinary tract infection
- pain during urination
- weak urine stream
- increased urinary frequency
- bedwetting or wetting pants after your child has been toilet trained
- poor weight gain
- difficulty urinating

Severe cases can lead to the following medical complications:

- difficulty breathing
- hydronephrosis (kidney dilation)
- bladder dysfunction
- impaired kidney function and an increased risk of kidney failure
- vesicoureteral reflux (when urine flows from the bladder to the kidneys).
- chronic kidney failure

Your child will be evaluated and treated by a group of qualified specialists from many different disciplines, including nephrology, urology, and radiology. Depending on the severity of the abnormality, posterior or anterior urethral valves may be treated with various surgical interventions and medical treatment. Treatment and management should be carried out as soon as possible after birth with surgical drainage of the bladder. These procedures can be performed endoscopically (laser fulguration), vesicostomy, or high urinary tract drainage.

Since boys with urethral valves have up to a 25 percent lifetime risk of kidney failure, Professor Rosito seeks to maintain bladder function as the primary goal of treatment. We will help your child prevent bladder function problems, incontinence, and urinary tract infections by regularly monitoring kidney function, bladder function, and emptying capacity (bladder emptying).

Ureteroceles are congenital defects that occur in approximately 1 in every 2,000 babies. They occur more frequently in Caucasians. If your child's ureter (a tube that carries urine from the kidney to the bladder) does not develop properly, it can dilate, forming a small pouch that can block the flow of urine. This bulge or pouch is called a ureterocele.

Ureteroceles are 10 times more common in girls than in boys because a duplicated collecting system (two ureters for one kidney) is more common in girls.

In some children with ureteroceles, there may also be reverse flow of urine to the kidney, which can damage the kidney (a problem called vesicoureteral reflux). Large ureteroceles can also protrude into the urethra and obstruct the flow of urine out of the bladder.

Ureteroceles are most often diagnosed in children under two years of age with an ultrasound or voiding cystourethrogram (VCUG). In many cases, the ureterocele or its effects are observed on ultrasound before birth.

Surgery is sometimes necessary to repair your child's ureterocele, but if the blockage is not severe, your child's doctor may choose to simply observe it for a while to ensure the condition does not worsen. Small ureteroceles may not require any treatment.

In cases requiring surgical treatment for decompression, Prof. Tiago Rosito initially uses endoscopic treatment with laser fulguration. In more severe or refractory cases, reconstruction of the lower urinary tract with ureteral reimplantation may be necessary.

Varicocele is the formation of varicose veins in the veins of the scrotum, where the testicles are located. Sometimes, varicocele appears when the man is still in adolescence, with its peak incidence between 15 and 25 years of age.

Varicocele can cause a decrease in the quality of semen produced by the man, as blood cannot circulate properly in the area. As a consequence, fertility may decrease. However, it is important to note that varicocele does not affect a man's sexual potency.

In many cases, men with varicocele do not experience any symptoms and may not even know they have the condition. However, the dilation of these veins, which is characteristic of varicocele, can cause aesthetic concerns for the patient, as it alters the appearance of the testicles. Varicocele can also cause a sensation of heaviness in the testicles, pain, and discomfort in the area.

The answer is yes, and the condition can be cured through surgical intervention, which has already shown good results in relation to infertility.

Varicocele in childhood is more complex to manage because, due to the sexual immaturity of children and adolescents, the sperm profile does not serve as a treatment guide. In boys and adolescents, annual monitoring with a physical exam and ultrasound by a pediatric urologist is essential.

Professor Rosito has extensive experience in managing children and adolescents with varicocele, providing follow-up from childhood to adulthood, increasing the safety of management and reducing the risks of infertility.

Transition urology is the specialty that accompanies the transition from childhood to adolescence and then to adulthood for children born with a urological alteration. It is very common to lose follow-up during this phase, which poses serious risks to the health and proper development of these children. This serves as a warning for parents to seek, from birth, a professional capable of accompanying their baby into adulthood without the need to change professionals. Professor Tiago Rosito created the first university outpatient clinic for Transition Urology in southern Brazil and one of the first in Latin America, being one of the leaders in this area throughout the Americas.

The vast majority of congenital (birth) urological diseases are, nowadays, diagnosed in the prenatal period through pregnancy monitoring ultrasounds. All fetuses diagnosed with any urological or genital alteration should be monitored by a pediatric urologist trained in the management of these alterations. This multidisciplinary evaluation aims to identify at-risk cases, provide counseling for parents and obstetricians, and prepare the follow-up that should be carried out immediately after birth.

Professor Tiago Rosito has been the Urologist of the Fetal Medicine Group at HCPA for over 15 years and has accompanied hundreds of pregnant women and their babies throughout this journey so important for any family.