In the present series the proportion of BSD children amongst the paediatric urolithiasis was 70.4% which was earlier reported to be 84.8% by Rizvi (1975) and 95% by Ilahi (1967). A similar proportion (77.6%) was reported in Egyptian children (Loutfi et a!., 1972). In Iran the proportion of BSD cases among all paediatric urolithiasis appear to have shown a decrease from 69% to 58.8% over the last ten years (Gharib, 1970; Sadre et al., 1973; Halim et aL, 1981). In India this proportion shows little change (from 85% to 87%) in Northern and Eastern regions (Andersen, 1962; Aurora et al., 1970; Singh et al., 1978). The pattern of childhood urolithiasis in Pakistan as well as in the neighbouring countries is derived from hospital based data whose bias in interpretation of the prevalence of disease is well known (Barker and Donnan, 1978; Williams, 1978; Scott et aL, 1981). Nevertheless, the pattern of paediatric urolithiasis appears to be undergoing some change in developing countries as well, more so in urban areas (Sutor, 1980), which may be an expression of regional specificities. It remains to be seen if change in the face of childhood urolithiasis, as seen in the west at the turn of the century, can be anticipated in Afro-asian countries, with achange in the socio-economic development in these countries.
The peak age group in BSD in the present study was between 2-4 years. Most of the workers from Egypt, Turkey, Iran, India, Thailand and Indonesia have reported similar findings (Eckstein, 1961; Valyasevi and Van Reen, 1968; Gharib, 1970; Aurora et al., 1972; Sadre et al., 1973; Thalut et al., 1976). This draws attention to the hypothesis that occurrence of bladder stones in these children may be a very early event (Haistead, 1977) and whether it relates to the age of weaning remains to be seen.
The number of male children suffering from BSD was much higher than females with a male to female ratio of 9:1 in the present study. This is in agreement with the reports from Turkey (11.9:1), Thailand (10:1), Indonesia (12:1) and Pakistan (8.5: 1) (Eckstein, 1961; Haistead and Valyasevi, 1967; Thalut et al., 1976; Rahman and Van Reen, 1981). A much higher prevalence of bladder stone disease in males has been reported from Northern India and Egypt, with male to female ratio ranging from•15.6:1 to 31:1 (Andersen, 1962; Aurora et al., 1970; Aurora, 1977; Loutfi and Abdel-Hamid, 1977). The male to female ratio in childhood urolithiasis in series from western countries varies between 1 .1 and 1:2 the predominance of childhood upper tract calculi in these countries being well documented (Myers, 1957; Ghazali et al.,1973; Malek, 1976; Churchill et al., 1980). Some workers have attempted to explain the male predominence on the basis of long tortuous urethra in male (Loutfi et al., 1972; Aurora, 1977). However, if it was only a question of passage of microlith the greater laxity and width of female urethra (Finlayson, 1977) may be of0greater relevance than the length of urethra.
Many workers consider high environmental temperature and humidity to be important contributory factors in the occurrence of renal/ureteric colic (Prince and Scardino,1960; Bateson, 1973; Elliot et a!., 1975; Fujita, 1979). Although a greater number of cases (102) were seen from March to August as compared to 78 cases seen between September and February, the difference was not statistically significant. This is in agree. ment with earlier reports which showed no significant seasonal relationship to the time of hospital reporting of BSD children (Andersen, 1962; Loutfi et al., 1974; Sastraomidjojo, 1977). There is need for further study of the relationship of temperature and humidity with the aggravatiQn of symptoms to a degree that these children seek medical help, although the stones have been present for a long time.
Many workers have reported a similar over all pattern of presenting symptoms (table 1) as shown in the present study with painful micturition being the commonest (Aurora et aI.,1970; Gharib, 1970; Khan, 1977; Teotia and Teotia, 1977). In younger age group (0-6 years) milking of penis was significantly more frequent than in older children while the intermittent obstruction was also significantly more common in the group with lesser duration of symptoms (table 1 ). Thalut and associates (1981)also found pulling penis to be the commonest symptoms in male children. It is probable that irritation of trigone by the smaller calculi together with its ball-valve action causes obstruction to the flow of urine and the child pulls at the penis to relieve both the obstruction and the irritation of the bladder neck.
Older children with larger stones are less likely to face this situation.
Haematuria was seen in 24.4% cases which is in agreement with reports from Thailand, Indonesia and India (Haistead and Valyasevi, 1967; Thalut et al., 1976; Teotia and Teotia, 1977). However, this is in contrast to childhood renal lithiasis where the frequency of haematuria ranges from 5 5-80% (Gaches et al., 1975; Puga et al., 1977; Noronaha et al., 1979). Whether this is due to the much richer blood supply of the kidney or greater area of mucosal contact of the stone in case of renal calculi needs further clarification.
Evidence of associated renal disease was seen in 20 (15.6%) patients. The Occurrence of upper tract calculi in childhood during the period of study was 23.5% and the cases of concomitant upper and lower tract calculi were 10% of all upper tract calculi. The probability that these concomitant cases are incidental overlap is quite low (P < 0.01 > 0.05). Thus the view that most of the bladder calculi have renal origin cannot be ruled out and there is still a need to consider BSD in the broader frame work of urolithiasis.
Majority of BSD cases (61.1%) in the present study showed no attributable cause for stone formation which agrees well with reports of idiopathic calculi in children from developing countries (Haistead and Valyasevi, 1967; Sadre and Ziai, 1977; Singh, 1977; Rahman and Van Reen, 1981; Brockis et al., 1981). In the present study stasis was shown to be a possible etiological factor only in 5% children, whereas some workers reported a higher percentage (Aurora et al., 1970; Taneja et al., 1970; DuPreez arid Cremin, 1973; Loutfi et al., 1974).. This may be because intravenous pyelography was done only in equivocal cases where plain x-ray despite presumptive symptoms was negative for bladder stone. In the present study 52 (28.9%) patients showed some metabolic’ disorder which could predispose to stone formation. This is in contrast to low reported incidence of metabolic causes for vesical calculi in Indian children (Aurora et al., 1970). There is a need for an indepth investigation of metabolic causes in these children in our region.
There was a significantly higher frequency of post-operative complication in the presence of urinary tract infections. In view of this a preoperative urine culture and appropriate treatment is strongly advocated to avoid this situation. It is also important to note that a stone needs to be removed suprapubically because of the complications that ensues on its impaction in the urethra (Malek, 1976; Drach, 1978). Some workers (Loutfi 1977; Singh et aL, 1968) have recommended closure of bladder leaving no uretheral catheter postoperatively. However, in our experience a catheter in the immediate postoperative period (12-24 hours) was beneficial as the child was likely to retain urine due to postoperative pain. This increased the likelihood of producing pressure on bladder repair thereby increasing the frequency of suprapubic leakage of urine.
Low recurrence rate following surgery (1 .2%) in the present study agrees well with other workers who have studied the problem of bladder stone disease in children (Valyasevi and Van Reen, 1968; Aurora et al., 1970; Loutfi, 1977; Brockis et al., 1981). This is in contrast to a recurrence rate of upto 30% for renal calculi in children (Deaschner et aL, 1960; Gaches et al., 1975; Malek and Kelalis, 1975). The low recurrence rate in childhood BSD appears to be attributable to some stone promoting events which have occurred in the remote past as an episode. Since the underlying factors do not persist, unlike renal stones, the stone forming process does not show the same activity as in upper tract calculi.
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