Trisha Williams (Host 1): Hi, guys. Welcome to the Advanced Practice Perspectives. I'm Trisha Williams.

Tobie O'Brien (Host 2): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced Practice Providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and giving you an inside look of the various advanced practice roles at Children's Mercy.

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Now that we have the housekeeping tasks out of the way, it's time to sit back, tune in, and get started. Today, we are pleased to have Azadeh Wickham visiting with us. Azadeh is a Urology nurse practitioner at Children's Mercy, Kansas City Hospital. And we are excited to discuss pediatric urological conditions. Welcome, Azadeh.

Azadeh Wickham: Thank you. Thank you for having me.

Host 2: We are so excited to talk to you about this. It's been a long time coming, so we are excited to have you. Please take a hot second and tell our audience a little bit about yourself.

Azadeh Wickham: Sure. Well, first of all, thank you for having me. I am Azadeh Wickham. I have been working with the Children's Urology Group here in Kansas City for the past 11 years. Prior to that, my experience was General Pediatrics and Public Health. And then, as a nurse, I did surgical ICU with some Urology background as well. I did General Urology as a NP for about a year, realized adults are not my jam. all as wonderful as they are. But I I love taking care of kids, so here I am. Yeah, and I have a crazy home life with five kids that are now all of them are teenagers with two sets of twins. So, life is just a beautiful chaos.

Host 2: Oh my goodness. Two sets of twins. Five kids. You win, girl. that is sounds like beautiful chaos.

Azadeh Wickham: it is beautiful chaos.

Host 1: I love that. Beautiful, beautiful chaos. I got to remember that when I feel like I'm drowning. It's beautiful chaos. I love it.

Azadeh Wickham: Keep reminding yourself of that.

Host 1: I know. I love it.

Host 2: Well, tell us about the different types of urologic conditions that are most common in kids.

Azadeh Wickham: Sure. So, the number one reason why for referrals to Pediatric Urology is urinary tract infections or lower urinary tract dysfunction, which is urinary tract infections are part of that diagnosis, that encompassing diagnosis. About 40% of referrals of Pediatric Urology is that lower urinary tract dysfunction, meaning urinary urgency, incontinence, nocturnal enuresis or nighttime wedding. All these things are in urinary tract infection, which I have mentioned earlier. So, that is the most common.

Then, the next thing that's followed is that I would say undescended testis, hydronephrosis, which is basically just fluid collection in the kidneys with or without an obstruction. And then, after that I would say hypospadias and then vesicoureteral reflux. Those are the most common conditions that we see in Pediatric Urology.

Host 1: In your practice, kind of talk about what are some of the most common diagnosis you see specifically? Like are they common or...?

Azadeh Wickham: So as an advanced practice provider, the beauty of Urology as a discipline is that it is a medical and surgical field, right? So, you have a lot of diagnoses that I mentioned other than undescended testes and hypospadias that can be managed medically. So obviously, I'm not a surgeon, so we don't do anything in the operating room, but what I do see is the medical side of things, which is the bowel bladder disorder, that's probably the most common condition that I see.

And then, followed by that is my specialty, is also taking care of children with neurogenic lower urinary tract dysfunction, which includes kids that have been born with spina bifida, kids that have spinal cord injury, traumatic or usually as a result of either a car accident or some sort of a different type of accident, sporting accident or whatever it may be, plus even some tumors that can result in spinal cord injury.

So, that is my two main things that I see. I do have about a half-day clinic that I do see surgical consults as well, where I see for circumcisions that were not done as a newborn or hypospadias, as I've mentioned, and undescended testicles. Those are the three main surgical things that I see.

The kids with hydronephrosis which is the collection of fluid in the kidney, that is a condition that can happen. I think it's one in 100 kids that are born with it. And mostly, it's more common in boys than girls. That condition really varies, right? So, that is a condition that the incidence have been higher because of our technology of prenatal ultrasounds, right? It really truly picks up on so much. So, I would say our parents, they could be walking around with when they were kids and had hydronephrosis, and they probably didn't even know it, right? And they were totally fine.

But now, because of the beauty of technology, we know these. And so, what we do is we do follow these kids, as I said, with serial ultrasound medically. And most of these kids do not need a surgical intervention, but we just need to make sure that there is no congenital obstruction that's resulting in this collection of fluid in the kidneys, right? So, I do see some of those kids, but really those kids, they start with seeing the surgeon, the urologist. And if they recognize that there's really no surgery needed, then they send it to us. And we can follow them as well.

So, those are my main things that I see. The beauty of Urology is it's got such a variety. And coming from a general pediatric background, seeing a lot of things. It's fun to not be limited to one diagnosis. We obviously all have our diagnoses that we kind of lean towards and we enjoy caring for, right? And I would say that mine are the children with neurogenic bladder. So, I truly do enjoy the independence and the autonomy of being able to practice, taking care of variety of conditions.

Host 1: So much more than just kind of what one would think.

Host 2: So as you take care of these kids, are there any-- since it is like funny, Tricia and I are also in like a medical-surgical type kind of setting in ENT. So, we're familiar with like all of this sort of balance between what you can do medically wise. But also, there's that balance with what just the surgeon can do. But in Urology, are there any kind of minor procedures that you are able to do in clinic?

Azadeh Wickham: Oh, absolutely. So, this is actually a big initiative with Pediatric Urology APPs at the moment. So, circumcisions, there are quite a bit of APP-led circumcision clinics, where how it works is that you usually have about six to eight weeks, and eight weeks is really on the far end of it. I would even say six weeks is probably the max that you have that window for a newborn circumcision if you desire circumcision, right?

And with that being said, there is either if there's some concern with like the anatomy or those circumcision devices are, they can't be fully accurate like a freehand circumcision can be, right? So if you have some high-riding scrotum, some tethering, ventral tethering or maybe even a slight curvature of the penis, that can throw off the appearance of the circumcision, and not to the fault of the provider, just because of the device, right?

And so, a lot of pediatricians, what they do is they want to have the reassurance for their patients, which is the right thing to do, and refer them to us. But then by that time, by the time they get to see us and whatnot, and we don't have the staff or the capability currently of doing in-office circumcisions. So, what happens is these kids get teed up for a surgical circumcision, which you don't do elective surgery in children really until six months of age because the risk of anesthesia is so much less. It's basically the same as an adult after six months of age. So then, now, you're exposing the kid to anesthesia, right?

So, what the initiative across Pediatric Urology is in the country, it's not just Kansas City, is that you have APP-led circumcisions, right? So, these newborn circumcision clinics. And so, that's one that we talked about. The other one that you could do minor procedures that you mentioned is you can have penile adhesions where the foreskin can stick to the glans of the penis. And this is so extremely common, right? And so, over time, what happens is that the adherence can be kind of dense, right? So, you really need to numb the kid and then pressure and reduce those adhesions, right? So, an advanced practice provider can do that. And also, you can develop what we call a band. So, you have the adhesions pulled back, but there's just maybe an area, a band that doesn't get resolved. And over time, it just basically becomes dense and it becomes a band. And so, you can also divide that band in clinic. And some of my colleagues have privilege of doing that. They've been credentialed to do that. Labial adhesions is another one.

Those are some minor procedures that Pediatric advanced practice providers can do in clinic.

Host 2: Okay. That's really interesting. I'm sure that does help with access to-- I could see across the country-- getting some sort of a standardization and access for all newborns. So, that's a really interesting and kind of cool initiative for the advanced practice providers.

Azadeh Wickham: Yeah, so access and utilization, right? So, it's going to cost so much more to go to the operating room to do a surgical circumcision versus doing an in-office circumcision, right? So, that is the big thing, and the anesthesia, right? We want to minimize anesthesia. Although extremely safe, you want to minimize the exposure to it. So, that's the biggest thing. So, not only the access, as you mentioned, but also the utilization and being good stewards of the finances, of healthcare finances as well. So, we don't drive up cost.

Host 1: Like being good stewards and like lowering the healthcare burden of, you know, the cost to the family and things. So, that's an amazing initiative. I love that.

Azadeh Wickham: Exactly. Yes. Yes.

Host 1: I kind of want to go back to taking care of your favorite population of patients and the neurogenic bladders and things like that. Tell me what goes into care of those patients.

Azadeh Wickham: Oh, see, this is why I think I love it. So, the reason why I love taking care of children with neurogenic bladder because neurogenic bladder, majority of my patients have spina bifida, right? They're born with spina bifida. And spina bifida is one condition that we call it-- it's a snowflake condition, even though you have the insult to the spinal column, or whatever the defect was, wherever the defect was, I guess I should say. So, it's not the same. You could have lumbar-level myelomeningocele, and still two kids with that have completely two different urologic symptoms, right? So, that's what makes it, I think, very fun because it's truly a personalized care to that family and patient.

The other thing is that I think the advancement of what we've done with caring for children with any type of urologic-neurologic condition is that the introduction of catheterization in the 1970s, and not just like these kids used to have to have-- well, number one reason why individual with spina bifida passed away was because of kidney failure, right? So, they went into chronic kidney disease and died from a chronic kidney disease and kidney failure. So with the introduction of clean intermittent catheterization in the 1970s, we also took away the risk of these infections that you would get with indwelling catheters, because that was the only thing that we had an option of before the 1970s.

So, another abbreviation that's very common in the Urologic world is CIC, which is the clean intermittent catheterization. That can be quite-- I don't want to use the word traumatizing-- but, like, families know that it's a possibility, but it's burdensome. That's a better word than traumatizing. It's an extreme burden, right? So, that is taking care of those kids and understanding the burden that it places on them and their families. That's why I love to really be part of that team, right? Because it's not just me, it's also I can provide the recommendations. But if you don't have the capability of executing my recommendations, then it doesn't do anybody any good, right?

So, that's why I think that's the piece that I really enjoy, thinking what resources there are out there working with families and really seeing the independence that comes with it, right? So, that's the piece that I really enjoy doing. And the other fun part of it is that they do have surgical reconstruction many of these patients do to make things easy and/or to help with continence, social continence.

And these are pretty involved surgeries that I get to be, not necessarily in the operating room part of, but I do the preoperative teaching. I clear them for the surgery. So, I'm in the process other than actually being in the operating room in all the steps of the process with these families. So, I go through it with them. And so, it just builds that relationship and, really, truly, it is such a gratifying part of my job.

Host 1: When you get to see those outcomes of the recommendations and the success that the family has with taking care of their kiddo, and then the kiddo having success as well is always a cup filler for me as well.

Azadeh Wickham: It is. I think that's why we all went into this, right? I mean, absolutely, that's part of it. But the other piece of it is that I want to, I guess, kind of build on that and say that not all families are going to-- So, being in underwear and being able to cath yourself and to have what we think of continence may not be a success story for every single family, but those baby steps can be it.

So, I'll provide an example for a family that I mean, this kid needed to catheterize because the kidney the bladder pressures were affecting the kidney function, right? So, this is something that's not just social, this is also a medical need as well. And they were having a tough time adhering to the recommendations. So, I said "What can I do to help you to make it easier for yourself for you to adhere to my recommendation?" And this was like a 12-year-old girl, right? She's got limited lower extremity mobility where she has to use a wheelchair, things like that. And she said, "I can't get into the bathroom. Our bathroom's not big enough for my wheelchair to get in, and the only place I can cath is in the living room. And I just don't want to do that in the living room." I mean, those are the stories that I hear, right? And these are things that we don't think of. So, there's more to it than just the frequency of catheterization and adhering to our recommendations.

Host 1: It's just important to keep in mind to figure out what those barriers are. You know, I think that that's a good point for all of our advanced practice providers. Like, if they're not adhering to the recommendations that we make, it's not because they don't care or they don't want to do it, you know, and figure out what those barriers are and then help them. So, kudos to you for figuring out what those were, and I'm sure you worked on a plan for her to be successful so that doesn't happen.

Azadeh Wickham: Yeah. I mean, yes, but it's extremely challenging because the resources-- and I'm not talking about the resources that we have in the clinics and that Children's Mercy can offer-- but I'm talking about resources that are offered in the community, right? So, there's not much I could do for a family who is facing financial hardship where they have to share multi-generational family in that small space. You can't do anything about that, unfortunately. I wish I could.

Host 2: Did you guys end up ever coming up with like a plan of what might be helpful to her?

Azadeh Wickham: Yeah. So, what this kiddo, if I remember correctly, was that we really worked with the school to try to get her catheterizations in the school and allow her bladder to cycle that way. I mean, wasn't a perfect scenario. That's why I mentioned you have to take everyone you can get, right?

It doesn't mean, as I say, I watch these families and work with these families and I love these success stories where they are completely dry and that, well, their kidneys are healthy, is number one. And then, that they're socially dry as well and they're able to be independent. But that looks different for all everybody in all families. So, you have to celebrate your wins when you can get them.

Host 1: You mentioned something about kidney health and kidney function, and I was wondering how closely you work with our Nephrology colleagues.

Azadeh Wickham: Yeah. I always tell my families with neurologic neurogenic bladder, or neurologic lower urinary tract dysfunction is another fancy word for it. So, I always tell my families I have three jobs, right? My job, number one job is to keep your kidneys healthy, right? Number two is to ensure that you don't get urinary tract infections, because repeated urinary tract infections affects kidney health. And then, third is for social continence and independence. So, those are my three main jobs for taking care of these families.

What we do, we follow the UMPIRE guideline, which is basically a group of pediatric urologists across the country that are participating in a NIH-funded study to develop guidelines for taking care of children with spina bifida from ages zero to five. And they provide us with guidelines of what studies need to be done at what interval. So, we follow that. And based on those studies, if there is abnormal lab values, because the nephrologists really are our medical kidney doctors, right? We always say we're the plumbers and they're the the medical piece of it, right?

And so, if there is, I definitely reach out to them and I'll tell you we have-- well, I mean, I don't have to brag about them because we know how great they are. We are so lucky to have such an amazing team of nephrologists and advanced practice nephrologists here at Children's Mercy, and we work so well together.

Host 2: I love the way that you put that with the plumbers, and that's funny. That's cool. Okay. Well, so as we think about our community, because part of our goal with this podcast is just to kind of help educate our community of advanced practice providers that might be sending their kids to Children's Mercy. Do you have any kind of tips or bits of education that you would love to pass on to outside APPs that could be considering sending a child over to see you? Are there any important points that you would want them to hear?

Azadeh Wickham: Yes. You know, I love this question because this is one question that, because our catchment area for caring for children with pediatric urology conditions is so big. So, we take care of kids from-- now, there was a group in Nebraska before, like when I first started over 10 years ago, there was not a group of pediatric urologists in Omaha. But now, there is. So, you can imagine from Omaha to Oklahoma City to Denver area and St. Louis is our catchment area, and some of Arkansas as well. So, that's another piece of it. So, we have a big area that we serve, right? And so, unfortunately, access can be challenging for us.

So, to answer your question is that I want to give pointers to our primary care colleagues where what they can maybe start with and then while they're waiting for the appointment or the referral to go through, right? So, we are the specialists. So, we're always happy to see. I feel like there is no inappropriate referral. That's one thing I can say, right? If the primary care provider feels that they need a urology input, fantastic. Send them our way. We'll be happy to see that kiddo.

But the most common condition, as I mentioned that we see is bowel and bladder disorder, including urinary tract infections, right? So to get good information, I think, for themselves and for us, is that if you notice that a lot of primary care providers where they check for a UA, they do a dipstick, right? Because that's the easiest thing to do, right? So if they notice that it's positive, I would recommend that they could send that out for microanalysis. That's one, because that really gives you a lot more information, and a culture. Those are the two main things that we do.

And then, the other helpful tip would be the collection of urine. It's really difficult sometimes with kids to collect a good specimen. And in general pediatrics, this was part of our practice as well when I was in it, was that you would collect it via bag if the kid is young enough or not toilet trained, or second, put it in a hat where they would void into a hat, and then you'd pour that into a cup and then send it off for analysis, right? So, understanding that once you don't do either a catheterized specimen for a non-toilet-trained child or a midstream clean catch urine in a toilet-trained child, that will add some difficulties into their interpretation, right? Because E. coli is a genital flora, right? It lives on our skin as well, which is the most common bacteria that causes urinary tract infection, or Klebsiella. And those two bugs, if you don't do clean catch or a catheterized specimen, can escape, I guess, or whatever you say into the specimen, right? And so then, it doesn't give you a clear picture if the child is truly having UTIs or not, which can lead to overtreatment with antibiotics and resistance, right?

So, my advice would be that, if possible, one, the collection method is very important to consider. To not do a hat collection for toilet-trained child and to not do a bag specimen in a non-toilet-trained child. So if you don't have the capability of cathing a baby in your practice, I understand that, I would send them to urgent care where I know our CMH Urgent Care, they're happy to see the child for a suspected UTI and cath. So, things like that.

And then, the second thing is that with the dipstick, it can be challenging to interpret that, especially if you don't get to it right on the time that it says you should read it, it can give you a false positive. And so, it's really important to send that off to the lab and have somebody look at that urine specimen under the microscope and culture it. So, those are my recommendations for our primary care colleagues.

Host 1: It's a great ask. I just wonder if there's some clinics and things kind of out in our rural community areas, especially like in our healthcare deserts and stuff in Missouri, if they have those capabilities of doing that.

Azadeh Wickham: Yeah, no, Absolutely, that's a challenge. And that's why when I say that if you don't have the catheter, it's just important to-- especially for a non-toilet-trained child-- to really make sure that it really is a UTI. And the best way to do that is to get a catheter specimen. So, it might be an ER visit, which to me that is a good use of healthcare system, because you really need that in information.

There's three main reasons why kids are diagnosed with bowel and bladder disorder or overactive bladder, okay? So, number one is that if when I say behavioral, it's more like habits where the child gets into the habit of withholding urine. And it'll be like the kid will wake up and parents will say, "I can't believe it. We have to remind her or him to go pee." And so, those are as a result of the kid ignoring the urge to void and the brain's kind of shut that signal off. So, we definitely say making sure that kids can void every two hours on a schedule. So, that's another easy recommendation for our primary care providers they can provide to their patients.

The second reason is dietary bladder irritants. So, I use myself as an example all the time when I talk to my families about this, I love coffee. Oh my gosh, do I drink coffee? It's such a kryptonite for me, I know. But guess what? Coffee is a bladder irritant because it's caffeine, right? So, anything with caffeinated beverages, and they say even carbonation. My colleagues across the country would say that you should stay from all artificial sweeteners and colors. I am mom of five and a realist, and I say that I know in the literature that it says that it really has shown that red dye 40, right? Red dye 40. Yes. I'm saying that correctly. Red dye 40 is a bladder irritant that can irritate the lining of the bladder and cause the bladder to be overactive. And then, final thing is citrus drinks, and I'm not talking about lemonade because that's mostly sugar and water, but grapefruit juice, which most kids don't really enjoy, or orange juice can be a bladder irritant. So, that's two.

And then the final, and probably the most important piece is incomplete evacuation of stool. So, I don't say constipation because when we think of constipation, we think of infrequent hard stool. What I'm describing is that these kiddos may poop every day, but they don't get rid of all the poop. And so, the rectal stool load remains prominent, right? And so, it pushes on the back of the bladder and causes that overactivity and these kids end up having urgency, incontinence, frequency. And so, even though the history may say that the kid is not "constipated", I would recommend an x-ray of the belly to just see what the stool burden looks like and addressing that. So, those are my recommendations for bowel and bladder disorder.

Host 1: Those are excellent recommendations. It makes me think of what I thought about my kids when they were growing up, about how they had things to do, they didn't want to miss out.

Azadeh Wickham: Oh yeah.

Host 1: So, they didn't want to go to the bathroom.

Azadeh Wickham: And that's Developmentally appropriate. That's why I hate to call it behavioral because it really is developmentally appropriate. It's just that it's not serving their bladder well, right? There is so much better things to do for a four or 5-year-old than to stop and pee. I mean, there are things to do in this world, right?

Host 1: Right. Right. That's why there's a lot of outdoor peeing for the little boys. Because they don't want to come inside and the little girls just hold it and...

Azadeh Wickham: Yeah, exactly. Yeah. If you want outdoor pee, I don't care. As long as you empty your bladder, it really doesn't bother me, as long as you don't end up with like some sort of a scrotal swelling or something like that

Host 1: Right. yeah, absolutely.

Host 2: Well, you have really shared such wealth of knowledge regarding these common urologic conditions that we all have seen in the past, and so we really appreciate your expertise on this matter.

Azadeh Wickham: You're welcome. I mean, I feel like the tip of the iceberg--

Host 2: This is just the tip.

Azadeh Wickham: Yeah, this is just a tip, and I could go on and on and talk about the different conditions, but I think those are the most common. And if there's ever any questions, please reach out to us. I mean, that's the one thing. This 1-800-GO-MERCY that we have is wonderful thing for our primary care providers that they could call and just say, "Hey, I have this patient. What do you think about this?" And we're happy to provide some recommendations and see if that helps the families as well.

Host 1: Right. It takes a village to take care of our kiddos, and we are blessed enough to be part of that village.

Azadeh Wickham: One-hundred percent. Yes. And I love being part of that village. Yes.

Host 1: To me as well.

Host 2: Well, we end each episode with the same question to each of our guests. So, this season, our question for you is, what is filling your cup in this season of your life?

Azadeh Wickham: Oh goodness. So, my family for sure, right? So, they always fill my cup. And I love to travel. And my husband and I have gotten a bad habit of taking all five kids on places we go, so now they're kind of like, "Oh, where are we going next?" So, that's really fun.

I would say the other things for professionally, I think what's really truly filling my cup is generating new knowledge, and that's why it led me to get my PhD recently and it just tells you that we're always evolving, right? Even at this stage of my career, I went back to school and got my PhD to learn more on how I can be a researcher and how to contribute to the literature. So, I mean, professionally, I think that's what's filling my cup. But overall, just being part of the village, like you said, it is definitely something that I look forward to.

Host 1: Well, Azadeh, we truly appreciate you sharing your knowledge with us and our community today. I hope that, and I know, that our guests will be able to take some helpful tips back to their own practice. So, thank you again for spending your morning with us.

Azadeh Wickham: Thank you for having me.

Host 2: If you have a topic that you would like to hear about or you are interested in being a guest, you can email us at tdobrien@cmh.edu or twilliams@cmh.edu. As a reminder, to complete your evaluation and ensure that you get the credit for listening, visit childrensmercy.org/appeval. That's childrensmercy.org/A-P-P-E-V-A-L. Once again, thanks so much for listening to the Advanced Practice Perspectives podcast.