Pediatric and Adolescent Care - Chapter 13 - Genitourinary System

First Nations and Inuit Health Branch (FNIHB) Pediatric Clinical Practice Guidelines for Nurses in Primary Care

The content of this chapter has been revised August 2010

Introduction

For more information on the history and physical examination of the genitourinary system in older children and adolescents, see the chapters, "Urinary and Male Genital System" and "Women's Health and Gynecology" in the adult clinical practice guidelines.

Assessment of the Genitourinary System

The genitourinary (GU) system may be affected by congenital abnormalities, inflammation, infection, other body systems or diseases of the kidneys.

History of Present Illness and Review of Systems

Newborns and infants with urinary tract disorders and diseases may present with the following signs and symptoms:Footnote 1

  • Pallor
  • Fever
  • Jaundice
  • Seizures
  • Dehydration
  • Poor feeding
  • Vomiting
  • Excessive thirst
  • Frequent urination
  • Screaming on urination
  • Poor urine stream
  • Foul-smelling urine
  • Enlarged kidney or bladder
  • Persistent diaper rash
  • Failure to thrive
  • Rapid respirations (acidosis)
  • Respiratory distress
  • Spontaneous pneumothorax or pneumomediastinum

The following signs and symptoms are those most commonly associated with urinary tract infection (UTI) in children:Footnote 2

  • Fever
  • Enuresis (bed-wetting)
  • Incontinence (new onset)
  • Dysuria
  • Hematuria
  • Frequency
  • Urgency
  • Change in colour or cloudy, foul-smelling urine
  • Abdominal, suprapubic, flank or back pain or tenderness
  • Scrotal or groin pain
  • Genital sores, swelling, discolouration
  • Lack of circumcision
  • Toilet-training problems
  • Irritability
  • Poor feeding

The following symptoms are associated with nephrotic syndrome and glomerulonephritis:

  • Swelling (for example, ankles, around eyes)
  • Headaches
  • Nosebleeds (an occasional symptom of hypertension, but nosebleeds also occur frequently in normal children)
  • Hematuria
  • Smoky or coffee-coloured urine
  • Decreased urinary output
  • Pallor
  • Weight gain

A complete history of the GU system should include questions related to:

  • Sexual activity (for adolescents)
  • Problems related to inappropriate touching by others (that is, sexual abuse)

Children must be asked such questions with sensitivity and without the use of leading questions. The parents or caregiver can be asked about these topics directly.

Physical Examination

Vital Signs

  • Temperature
  • Heart rate
  • Respiratory rate
  • Blood pressure

Urinary System (Abdominal Examination)

For full details, see "Physical Examination" in the pediatric chapter, "Gastrointestinal System".

Inspection

  • Abdominal contour, looking for asymmetry or distention (a sign of ascites)
  • Abdominal pulsations
  • Peripheral vascular irregularities
  • Masses

Percussion

  • Determine organ size
  • Liver span (may be increased in glomerulonephritis)
  • Ascites (dull to percussion in flanks when child is supine; location of dullness shifts when child changes position)
  • Tenderness over costovertebral angle

Palpation

  • Size of liver and any tenderness because of congestion
  • Identify local areas of pain or mass lesions
  • Kidneys are often palpable in infants, the right kidney being most easily "captured;" perform deep palpation to determine kidney size and tenderness (place one hand under the back and the other hand on the abdomen to try to "capture" the kidney between the hands)

Male Genitalia

Perform examination with the child supine and, if possible, in the standing position.

Penis

Inspection:

  • In the neonate, examination should focus upon possible congenital anomalies
    • Penile length
    • Foreskin anatomy
    • Location of the urethral meatus
    • Scrotal anatomy (including rugae)
    • Presence and location of the testes
  • Presence of abnormal scrotal or inguinal masses
  • Position of urethra (for example, epispadias, hypospadias)
  • Discharge at urethra (distinguish poor hygiene from urethritis)
  • Inflammation of foreskin or head of penis (sign of balanitis)

Palpation:

  • Foreskin adherent at birth normally
  • In 90% of uncircumcised male children, the foreskin becomes partially or fully retractable by 5 years of ageFootnote 4
  • Inability to retract foreskin (phimosis)
  • Inability of retracted foreskin to return to normal position (paraphimosis)
Scrotum and Testicles

Inspection:

  • Scrotum may appear enlarged
  • Check penile and scrotal skin for any unusual lesions
  • Check for edema (a sign of glomerulonephritis), hydrocele (transillumination should be possible), hernia, varicocele or abnormal masses

Palpation:

  • Cremasteric reflex (absent in testicular torsion)
  • Testicular size, position, consistency, shape and descent into scrotum
  • Testicular tenderness: consider torsion or epididymitis (pain is actually in the epididymis, not the testicle)
  • Swelling in inguinal canal: consider hernia or hydrocele of spermatic cord
  • Mass in scrotum

For information about examining the adolescent male, see "Assessment of the Genitourinary and Male Genital Systems" in the adult chapter, "Urinary and Male Genital System".

Female Genitalia

The clinician must be sensitive regarding the genitourinary examination of the older female child. Male providers should request the presence of a parent or delegate during the examination. At the onset of the examination of the genitalia, explain to the patient why examination of the area is needed and how it will be performed, including what instruments, if any, will be used.

  • Child should be in supine frog-leg position for examination
  • Do not perform an internal vaginal examination in a prepubescent child or an adolescent who is not sexually active
  • Spread labia by applying gentle traction toward examiner and slightly laterally to visualize the vaginal orifice
Inspection
  • Vulvar irritation
  • Erythema (in prepubescent girls, the labia normally appears redder than in adult women because the tissue is thinner)
  • Ulcerative or inflammatory lesions
  • Urethral irritation (sign of UTI)
  • Vaginal discharge
  • Bleeding
  • Enlargement of vaginal orifice
  • History and observations should concur or may indicate sexual abuse

For information about examining the adolescent female, see "Assessment of the Female Reproductive System" in the adult clinical practice guidelines.

Common Problems of the Genitourinary System

Glomerulonephritis

Disease in which there is immunologic or toxic damage to the glomerular apparatus of the kidneys. It can occur acutely (acute glomerulonephritis) or it may have a chronic or insidious onset (chronic or progressive glomerulonephritis).

Acute Post-Streptococcal GlomerulonephritisFootnote 5

Acute post-streptococcal glomerulonephritis (APSGN) is caused by glomerular immune complex disease induced by specific nephritogenic strains of group A beta-hemolytic Streptococcus. It is the most common of the noninfectious renal diseases in childhood. APSGN can occur at any age but primarily affects early school-aged children, with a peak age of onset of 6 to 7 years. It is uncommon in children under age 2.

Causes
  • Usually secondary to previous streptococcal infection (for example, of the throat or skin)
  • Follows pharyngitis or otitis by 1-3 weeks
  • Lag time after skin infections is variable (can be up to 3 weeks)
History
  • Acute onset
  • Usually history of pharyngitis or impetigo about 10 days before the abrupt onset of dark urine
  • Acute phase lasts about 1 week
Systemic Symptoms
  • Anorexia
  • Periorbital edema
  • Decreased urination
  • Smoky or coffee-coloured urine
  • Mild to severe hypertension
  • Abdominal pain
  • Fever
  • Headache
  • Lethargy
  • Fatigue, malaise
  • Weakness
  • Rash, impetigo
  • Joint pain
  • Weight loss
Physical Findings

The physical findings are variable and may include the following:

  • Edema (in about 85% of cases)Footnote 6
  • Hypertension (in about 80% of cases)Footnote 6
  • Hematuria (30% of children have gross hematuria)Footnote 6
  • Proteinuria
  • Oliguria
  • Renal failure (to variable degree)
  • Congestive heart failure
  • Hypertensive encephalopathy (rare)

Edema, hypertension and hematuria are the most common and most worrisome symptoms.

Differential Diagnosis
  • Other forms of glomerulonephritis, which have many similar features (distinguished by laboratory tests, renal biopsy and other diagnostic methods)
  • Acute hemorrhagic cystitis (no edema, hypertension, renal failure; does involve dysuria, frequency, urgency)
  • Acute interstitial nephritis
  • Antiglomerular basement membrane disease
  • Cryoglobulinemia
  • Nephritis, lupus
Complications
  • Acute renal failure
  • Congestive heart failure
  • Pulmonary edema
  • Sepsis
  • Hyperkalemia
  • Severe hypertension
  • Chronic renal failure
Diagnostic Tests

The diagnosis is made on a clinical basis and is confirmed by the following tests:

  • Urinalysis (hematuria, proteinuria)
  • Hemoglobin decreased (mild anemia)
  • WBC count increased
  • Recent throat swab positive for Streptococcus A infection
Management
Goals of Treatment
  • Prevent, if possible, by early treatment of all streptococcal infections (skin and pharyngeal)
  • Prevent or treat complications
Appropriate Consultation

Consult a physician immediately if you suspect this disorder.

Nonpharmacologic Interventions

While awaiting transfer:

  • Bed rest
  • Fluid restriction (to 60 mL/kg per day + urine losses)
  • Sodium-restricted diet
  • Correction of electrolyte imbalance
Pharmacologic Interventions

None, unless complications develop. Treat complications only on physician's instruction.
In patients with evidence of persistent infection (that is, those with positive cultures), the underlying streptococcal infection can be treated with penicillin or erythromycin.

Monitoring and Follow-Up while Awaiting Transfer
  • Fluid restriction (to 60 mL/kg per day + urine losses)
  • Monitor blood pressure and vital signs
  • Daily weight
  • Respiratory status
  • Renal function
  • Monitor intake and output
  • Watch for major life-threatening problems, such as acute renal insufficiency with electrolyte abnormalities, fluid overload, pulmonary edema, congestive heart failure, acute hypertension
Monitoring and Follow-Up over the Long Term
  • Will depend on cause and type of condition
  • Post-streptococcal glomerulonephritis usually has no long-term sequelae, but other types of glomerulonephritis may have long-term complications, including recurrence and chronic renal failure
  • Consulting specialist will provide instructions for surveillance
Referral

Medevac.

Chronic or Progressive GlomerulonephritisFootnote 5

Chronic glomerulonephritis (CGN) is characterized by irreversible and progressive glomerular and tubulointerstitial fibrosis, ultimately leading to a reduction in the glomerular filtration rate and retention of uremic toxins. In cases where CGN is not associated with other diseases, it may go undetected for years and be relatively asymptomatic until kidney destruction produces a marked reduction in kidney function. Consequently, the disease is more common in adolescents than in younger children.

Hydrocele (Physiologic)Footnote 7 ,Footnote 8

A hydrocele is a collection of peritoneal fluid between the parietal and visceral layers of the tunica vaginalis testis or along the spermatic cord.

Hyroceles are the most common cause of scrotal swelling and are relatively common in newborns, appearing in approximately 6% of full-term male neonates. They rarely occur in infant girls, in which they would present as a firm swelling in the groin.

Hydroceles may be communicating or noncommunicating.

Causes

Communicating Hydroceles
  • Usually develop as a result of failure of the processus vaginalis to close during development; the fluid around the scrotum is peritoneal fluid
Noncommunicating Hydroceles
  • Fluid accumulation may be caused by infection, trauma, tumour, an imbalance between the secreting and absorptive capacities of scrotal tissues or an obstruction of the lymphatic or venous drainage in the spermatic cord
  • This leads to a displacement of fluid in the scrotum, outside the testes
  • Subsequent swelling leads to reduced blood flow to the testes

History

  • Painless swelling in scrotum
  • Congenital or acquired
  • Hydroceles that are present in newborns, whether communicating or noncommunicating, usually resolve spontaneously by the first birthday, unless they are accompanied by an inguinal hernia 
  • Swelling may fluctuate in size

Physical Findings

  • Should be able to palpate an upper border of the swelling
  • Soft, nontender fullness within the hemiscrotum
  • Transillumination of the swelling should reveal a homogenous glow without internal shadows
  • Inguinal hernia may also be present
  • Examination of patients with hydroceles should include palpation of the entire testicular surface for findings of epididymitis, orchitis, testicular torsion, torsion of the appendix testis or appendix epididymis, trauma or tumour as the primary etiology

Hydrocele of the spermatic cord may also be seen:

  • Painless cystic swelling along the inguinal canal
  • Swelling may transilluminate

Differential Diagnosis

  • Enlargement of groin node
  • Trauma
  • Cystic lesion
  • Hematoma
  • Neoplasm

Complications

  • Slight increase in risk of inguinal hernia
  • Testicular atrophy
  • Epididymitis

Diagnostic Tests

  • The diagnosis of hydrocele can be made by physical examination and transillumination of the scrotum demonstrating a cystic fluid collection

Management

Goals of Treatment
  • Observe until condition resolves spontaneously or surgical referral becomes necessary
Appropriate Consultation

Consult physician in the following circumstances:

  • Diagnosis is unclear
  • There are signs of complications (for example, infection)
  • There is an associated inguinal hernia
Nonpharmacologic Interventions
  • Scrotal elevation
  • Explain to parents or caregiver the pathophysiology of the defect
  • Reassure the parents or caregiver
  • Advise parents or caregiver to return to the clinic if the mass enlarges
Monitoring and Follow-Up

Reassess every 3 months until resolution occurs or referral becomes necessary.

Referral

Referral to a physician may be necessary if there are signs of complications (for example, if there is an associated inguinal hernia) or resolution does not occur when expected (by 1 year of age).

Surgical treatment is considered in the following circumstances:

  • No signs of resolution by age 1 year (surgery may be delayed until age 2 or 3 in some circumstances)
  • Hernias are associated with the hydrocele

Prepubescent Vaginal DischargeFootnote 9

For vaginal discharge in adolescents, see "Vulvovaginitis" in the adult chapter, "Communicable Diseases".

Definition

Physiologic discharge:

  • Mucoid
  • Nonmalodorous
  • Seen in newborns and premenarchal girls (see "Tanner stage II and III" in the chapter, "Adolescent Health")
  • Normal vaginal secretions are often increased midcycle in adolescents

Any other discharge is a symptom of underlying problems.

Vaginal discharge is uncommon in girls < 9 years old.

Causes and Associated Organisms

  • Poor hygiene (Escherichia coli)
  • Moisture (especially resulting from synthetic fibre underwear, tight clothing, wet swimsuits, obesity)
  • Chemical irritants (bubble baths), local trauma
  • Poor estrogenization is a common factor that makes the vulvar tissues vulnerable to irritation and infection
  • Autoinoculation from associated upper respiratory tract infection (URTI) (Haemophilus influenzae, group B Streptococcus) or skin infections (Staphylococcus)
  • Pinworms (E. coli)
  • Foreign body (associated with E. coli)
  • Other skin diseases affecting the genital area (for example, eczema)
  • Specific infection: Candida, Chlamydia, Neisseria gonorrhoeae, Trichomonas (uncommon), bacterial vaginosis

If N. gonorrhoeae or Chlamydia is the cause of the discharge and the child is underage for consensual sex (that is, < 16 years), sexual abuse must be considered.

History

  • Various degrees of perineal discomfort or itching
  • Vaginal discharge - note onset, quantity, colour, type, odour, consistency and duration
  • Dysuria
  • Enuresis
  • Frequency
  • Recent medications, especially antibiotics
  • Associated illnesses (for example, URTI, skin problems, pinworms)
  • Hygiene
  • Use of harsh soaps and bubble bath
  • Tight-fitting or nylon underwear or clothing
  • Possible sexual abuse

Physical Findings

Do not perform a vaginal speculum examination or restrain the child.

  • Suboptimal general or perineal hygiene
  • Signs of URTI or skin disease
Labial Irritation
  • Consider problems with perineal hygiene or local chemical irritation (soaps, moisture)
  • Candida infection
  • Sexual abuse
Marked Erythema
  • Consider Candida infection
Vaginal Discharge
  • May be nonspecific
  • Thick, white, cheesy: possibly Candida
  • Frothy, green: likely bacterial, Trichomonas
  • Dark brown, foul smelling: possibly from a foreign body
Foreign Body
  • May be visualized better if child is in knee-chest position
  • May be palpated while doing a rectal examination

Differential Diagnosis

Noninfectious
  • Poor hygiene
  • Chemical irritation (for example, from bubble bath)
  • Foreign body
  • Trauma
  • Atopic dermatitis
  • Psoriasis
  • Seborrhea
  • Labial adhesions
  • Systemic diseases (for example, Kawasaki or Crohn's)
Infectious
  • Group A Streptococcus infection
  • Nonspecific bacterial infection
  • Pinworms
  • Candida (less common)
  • Sexually transmitted infection (STI) (consider sexual abuse)

Complications

The complications depend on the underlying cause.

  • Localized perineal irritation
  • UTI
  • Abdominal pain (with pinworms or UTI)
  • Vaginitis
  • Bleeding (from trauma)
  • Labial adhesions

Diagnostic Tests

If child is cooperative, attempt to swab vaginal orifice (using small, calcium alginate-tipped swab); avoid touching the hymenal edge. Swab for Chlamydia, N. gonorrhoeae, culture and sensitivity and hanging drop, in that order.

  • Urine for routine and microscopic analysis
  • Urine for culture and sensitivity
  • pH of vaginal secretions

Hormonal levels may be indicated in females with dry vaginal orifice. Consult physician or nurse practitioner if this is a finding.

Management

Management depends on cause.

Goals of Treatment
  • Identify and correct underlying cause
Appropriate Consultation

Consult a physician if the child is febrile or has abdominal pain, or if you suspect sexual abuse.

Consider sexual abuse if you suspect nonexploitative sexual activity with a partner more than 2 years older than themselves. Refer to "Child Maltreatment" for age-related definitions of child abuse. Also refer to "Child Maltreatment" for provincial legislation on reporting maltreatment and abuse in children.

Nonpharmacologic and Pharmacologic Interventions

For poor hygiene:

  • Improve perineal hygiene
  • Avoid bubble baths
  • Wipe from front to back, but avoid scrubbing genitalia

For foreign body:

In an older child who can cooperate, remove the foreign body if visible and within easy reach; otherwise consult a physician about options for removal.

amoxicillin (Amoxil), 50 mg/kg/day, divided tid, PO for 7-10 days while awaiting removal of foreign body

For pinworms:

See "pinworms" in Chapter 18, "Communicable Diseases".

For candidal infection:

clotrimazole 1% cream PV qd × 7 days

For trichomonal infection:

for age > 13 years, metronidazole (Flagyl), 2 g PO stat
for age < 13 years, consult a physician regarding dosage

For bacterial vaginosis:Footnote 10

Preferred regimen:
metronidazole (Flagyl, generics), 500 mg PO bid × 7 days

Alternative regimen:
metronidazole (Flagyl, generics), 2 g PO stat

For STI:

Consult a physician, a certified sexual health nurse or a nurse practitioner if you suspect an STI in a preadolescent child. Refer to and follow the  Canadian Guidelines on Sexually Transmitted Infections.

If the cause of the discharge is uncertain, send samples for culture and sensitivity and consult a physician or nurse practitioner for therapeutic options.

Report as suspected sexual abuse all cases of gonorrhea and Chlamydia infection in girls where the legal definition of sexual abuse is met. Refer to "Child Maltreatment" for age-related definitions of child abuse. Other cases of vaginitis may be reportable, depending on the circumstance.

Urinary Incontinence (Enuresis)Footnote 11 'Footnote 12

Urinary incontinence is the uncontrolled leakage of urine, which can be continuous or intermittent. Incontinence is twice as common in boys as in girls.Footnote 12

Causes

Night-time incontinence:

  • Slower physical development
  • Excessive output of urine during sleep
  • Anxiety
  • Genetics
  • Obstructive sleep apnea

Daytime incontinence:

  • Overactive bladder
  • Infrequent voiding
  • Small bladder capacity
  • Structural problems
  • Anxiety-causing events
  • Drinks and foods that contain caffeine

History

  • Primary enuresis is wetting in a child who has never been dry for at least 6 months
  • Secondary enuresis is wetting that begins after at least 6 months of dryness
  • Nocturnal enuresis is wetting that usually occurs during sleep
  • Diurnal enuresis is wetting when awake, also called daytime incontinence

Differential Diagnosis

  • Urinary tract infection

Complications

  • There is a clear association between voiding dysfunction and urinary tract infection (UTI)
  • Voiding dysfunction may predispose children to recurrent UTI and renal injury
  • The risk of bladder colonization and UTI is increased in children with incomplete bladder emptying due to dysfunctional voiding or underactive bladder

Management

Goals of Treatment
  • Rule out other causes (for example, infection)
Nonpharmacologic Interventions
  • Moisture alarms
  • Bladder training and related strategies:
    • exercises for strengthening and coordinating muscles of the bladder and urethra
    • determining bladder capacity
    • drinking less fluid before sleeping
    • developing routines for waking up
    • urinating on a schedule (for example, every 2 hours)
    • avoiding caffeine or other foods or drinks that may contribute to incontinence
Pharmacologic Interventions

A complete urological review in consultation with a physician is required before medication is prescribed for urinary incontinence.

Urinary Tract Infection

See also "Common Problems of the Urinary System" in the adult chapter "Urinary and Male Genital System".

Bacterial invasion of the genitourinary (GU) tract with resulting infection.

  • Cystitis: infection affecting only the lower GU tract (for example, the bladder)
  • Pyelonephritis: ascending infection involving the upper GU tract (for example, the ureters and kidneys)

Urinary tract infection (UTI) is the most common genitourinary disease in children. The prevalence of UTI is highest in boys younger than 1 year and girls younger than 4 years. Uncircumcised male infants, when presenting with fever, have a four- to eight-fold higher prevalence of UTI than circumcised male infants. Female infants have a two- to four-fold higher prevalence of UTI than male infants. This has been presumed to be the result of the shorter female urethra. As for uncircumcised male infants, the higher incidence is thought to be related to the mucosal surface of the uncircumcised foreskin being more likely to bind uropathogenic bacteria. In uncircumcised boys, a possible partial obstruction of the urethral meatus by a tight foreskin may be the explanation for the higher incidence of UTI.Footnote 13 An increased incidence of UTI is observed in adolescents, notably in those who are sexually active.Footnote 14

Causes

Bacterial invasion by one of the following organisms:Footnote 14

  • Escherichia coli in over 80% of casesFootnote 15
  • Staphylococcus aureus
  • Enterococcus spp.
  • Klebsiella spp.
  • Proteus mirabilis
  • Pseudomonas spp.
  • Haemophilus spp.
  • Coagulase-negative staphylococci

Predisposing factors:

  • Congenital GU tract abnormalities, for example, vesicoureteral reflux, short urethra (however, most children with UTI have a normal GU tract)
  • Perineal fecal contamination because of inadequate hygiene
  • Infrequent voiding or urinary stasis
  • Perianal infections
  • Sexual activity

History

The history depends on the child's age.

Neonates and Infants
  • Primarily nonspecific, non-urinary symptoms
  • May present with septicemia
  • Fever
  • Irritability ("colic")
  • Poor feeding
  • Vomiting
  • Loose stools
  • Jaundice (particularly in neonates)
  • Hypothermia
  • Failure to thrive
  • Decreased activity, lethargy
Younger Children (≤ 3 Years Old)
  • Abdominal complaints including pain
  • Suprapubic tenderness
  • Fever -- infants and children younger than 2 years can present with fever as the sole manifestation of UTIFootnote 17
  • Frequency, urgency, dysuria, enuresis
  • Urinary retention
  • Lack of circumcision in boysFootnote 18
Older Children (>3 Years)
  • May present with chronic urinary symptoms - incontinence, lack of proper stream, frequency, urgency, withholding maneuvers
  • Chronic constipation
  • History of previous UTI
  • Fever
  • Dysuria
  • Flank or back pain
  • In sexually active girls, barrier contraception with spermicidal agents predisposes to UTI

Physical Findings

  • Fever (may be absent in simple cystitis)
  • Suprapubic tenderness (in cystitis)
  • Tenderness of abdomen, flank and costovertebral angle (more likely with pyelonephritis)
  • Hematuria

Be sure to assess hydration status.

Differential Diagnosis

Distinguish between cystitis and pyelonephritis.

Infection of the Lower GU Tract (Cystitis)
  • Urethral irritation (for example, bubble bath, scented soaps or powders)
  • Urethral trauma
  • Diabetes mellitus
  • Masses adjacent to bladder
Infection of the Upper GU Tract (Pyelonephritis)
  • Gastroenteritis
  • Pelvic inflammatory disease (PID) (Chandelier sign with bimanual examination)
  • Tubo-ovarian abscess
  • Appendicitis
  • Ovarian torsion

Complications

  • Recurrent UTI
  • Sepsis, especially in neonates and infants < 6 months of age
  • Renal damage leading to adult hypertension, renal failure

Diagnostic Tests

Urinalysis for routine and microscopic examination (midstream specimen for older children, catheter specimen for infants).

Bagged urine specimens are of no value in diagnosing a UTI in infants, even if positive.

  • White blood cells (WBCs)
  • Bacteriuria
  • Hematuria (blood in urine)
  • Positive for nitrates (although UTI can occur with organisms that do not produce nitrate)

Urine for culture and sensitivity:

  • Preferably a first morning specimen; in infants, use a clean catheter specimen
  • If multiple organisms present on culture, suspect contamination, not true infection
  • Complete blood count, serum creatinine and blood cultures should be obtained if the child is febrile and systemically unwell

Radiologic Evaluation ,

  • A renal and bladder ultrasound is the least invasive method to visualize the kidneys and bladder, and should be used primarily to screen for an obstruction or abscess when resolution of UTI symptoms is slower than expected
  • Infants and young children with a UTI should undergo radiologic imaging to examine the urinary tract for structural abnormalities if there is no significant improvement of symptoms after 2 days of antimicrobial therapy

Management

Lower GU infections (for example, cystitis) are generally less severe and usually managed on an outpatient basis. Pyelonephritis is more severe and may require hospital care for intravenous (IV) antibiotics. The decision about hospitalization depends on the child's age and the severity of the clinical condition.

Goals of Treatment
  • Eradicate infection
  • Prevent recurrence
  • Identify underlying factors
Appropriate Consultation

Consult a physician for any of the following:

  • Recurrent urinary tract infections where imaging (renal ultrasound or scan, voiding cystourethrogram) may be requiredFootnote 19
  • Neonatal infections, for which medevac is required; these are often associated with bacterial sepsis and require IV treatment
  • Suspected pyelonephritis, for which child may be admitted to hospital (depends on age and severity of illness)

Cystitis

Nonpharmacologic Interventions
  • Increase rest if febrile
  • Increase oral fluids to promote urine flow
Pharmacologic Interventions

Do not treat as UTI unless results of appropriately collected urine specimens support the diagnosis (for example, positive for nitrates or WBCs).

Antibiotics:

trimethoprim-sulfamethoxazole (TMP-SMX, Septra and generics)

The dose is calculated on the basis of the trimethoprim component not sulfamethoxazole

Suspension contains TMP 40 mg / SMX 200 mg per 5 mL

trimethoprim-sulfamethoxazole: 5 - 10 mg TMP/kg per day divided bid, PO for 7 - 10 days

Consult a physician for choice of antibiotics if child is allergic to sulfonamides ("sulpha" drugs).

The efficacy of long-term antibiotic prophylaxis of recurrent UTI in children is not established.Footnote 15

Client Education

UTI can be prevented by:

  • Proper toileting (wipe from front to back)
  • Drinking plenty of fluids each day
  • Encouraging cranberry juice to prevent urinary tract infections.Footnote 22 ,Footnote 23 Cranberry juice is not effective for the treatment of UTIFootnote 24
  • Urinating when the urge is felt, not holding it in
  • Emptying the bladder after intercourse (sexually active teenagers)

Pyelonephritis (Suspected)

Adjuvant Therapy
  • IV therapy with normal saline may be necessary for children with pyelonephritis (before transfer)
  • Run at a rate sufficient to maintain hydration
Pharmacologic Interventions

IV antibiotics may be started before transfer, on the advice of a physician:

ampicillin 100-200 mg/kg/day, divided q6h, IV/IM
and
gentamicin (Garamycin), 5-7.5 mg/kg/day, divided q8h, IV/IM

Monitoring and Follow-Up
  • If treating as an outpatient, follow up in 24-48 hours. Review sensitivity of organisms to antibiotics when the results of urine cultures are available
  • If there is no response to oral antibiotics within 48-72 hours or if symptoms are deteriorating, consult with a physician about changing the antibiotic or the need for IV antibiotic therapy
Referral
  • Medevac all infants under 4 months of age, and those who appear acutely ill (at risk of sepsis), dehydrated or who are unable to tolerate oral medications or fluids
  • Older infants and children with suspected pyelonephritis may require medevac, depending on their clinical condition (for example, acute illness [sepsis], dehydration or if unable to tolerate oral medications or fluids)
  • Refer to a physician (for evaluation) any child with culture-proven UTI who has been treated on an outpatient basis

Emergency Problems of the Male Genital System

Abnormal twisting of spermatic cord and testis, which compromises blood supply to these structures and results in ischemic injury and pain. Acute, severely painful condition.

Torsion can occur at any age; however, it is most common in adolescence, with a peak at 14 years of age.

Testicular torsion is a medical emergency. If the blood supply to the testis is cut off for more than about six hours, permanent damage to the testis is likely to occur.

Partial or Intermittent Testicular Torsion

Torsion is not an all-or-nothing phenomenon. It can be complete (usually twisting > 360°), incomplete or intermittent.

Some boys and men have occasional warning pains in a testis before developing full-blown torsion. These episodes occur suddenly, last a few minutes, then remit suddenly. The pain occurs if a testis twists a little, and then returns back to its normal place on its own.

Incomplete or partial testicular torsion is difficult to diagnose because of its subacute presentation with nonspecific symptoms and signs.

Causes

  • Torsion is usually spontaneous and idiopathic (often occurs during sleep)
  • Predisposing structural (genetic) defect (for example, inadequate fixation of testis to tunica vaginalis, bell clapper deformity)
  • Occasionally caused by minor trauma to the groin
  • Strenuous physical activity
  • Sexual activity or arousal
  • Undescended testicle
  • Testicular tumour

History

  • Sudden onset of severe, constant, unilateral pain in scrotum or testicle, usually for < 12-24 hours
  • Prior episodes of intermittent testicular pain may be reported (torsion and then detorsion)
  • Pain may radiate to lower abdomen
  • May be described as abdominal or inguinal pain by the embarrassed child
  • Pain made worse by elevation of scrotum
  • Pain not relieved by lying down
  • Decreased appetite, nausea and vomiting may be present
  • Urinary frequency may uncommonly occur
  • Causes as listed above

For intermittent torsion:

  • Intermittent sharp testicular pain (resolves within seconds to minutes)
  • Long periods without symptoms
  • Number of occasions it occurred

Physical Findings

  • Temperature usually normal
  • Heart rate elevated
  • Blood pressure mildly elevated (because of pain)
  • Client in acute distress
  • Client bent over or unable to walk
  • Unilateral scrotal swelling and redness
  • Testis acutely tender, may be warm
  • Testis swollen and found higher up (retracted) in the scrotal sac than expected on affected side
  • Slight elevation of the testis increases or has no effect on pain
  • Testis might be lying horizontally (epididymis not posterolateral)
  • Hydrocele and scrotal skin erythema may be present (often a later finding)
  • Cremasteric reflex (elevation of testis after stroking the upper, inner thigh on the same side) almost always not present

For intermittent torsion, in addition to the above, the following may also be present:

  • Very mobile testes
  • Bulky spermatic cord
  • Normal examination

Differential Diagnosis

  • Epididymitis
  • Orchitis
  • Trauma
  • Hernia
  • Hydrocele
  • Incarcerated or strangulated inguinal hernia
  • Torsion appendix testis
  • Acute varicocele
  • Testicular tumour
  • Scrotal abscess
  • Testicular infarction
  • Henoch-Schonlein purpura
  • Appendicitis

Complications

  • Testicular atrophy
  • Infarction of testicle
  • Infection
  • Abnormal spermatogenesis
  • Infertility

Diagnostic Tests

  • Doppler ultrasonography helps distinguish testicular torsion from strangulated hernia, undescended testes or epididymitis
  • If testicular torsion is present, a slight elevation of the testis increases pain whereas in epididymitis it relieves pain

Management

Goals of Treatment
  • Relieve pain
  • Prevent complications
Appropriate Consultation

If you suspect a testicular torsion, initiate a consultation with a physician without delay. This is a medical emergency; prompt diagnosis and surgical referral is critical to a satisfactory outcome.

If intermittent torsion is suspected consult a physician.

Nonpharmacologic Interventions
  • Nothing by mouth before surgery
  • Bed rest
  • Promote the patient's comfort
Adjuvant Therapy
  • Start intravenous (IV) therapy with normal saline
  • Adjust IV rate according to age and state of hydration
Pharmacologic Interventions

Analgesia:

morphine 0.05-0.2 mg/kg/dose SC/IM/IV (maximum doses vary but generally should not exceed morphine 5-10 mg)

Usual maximum dose:Footnote 31

  • Infants: 2 mg/dose
    Note: Infants < 3 months of age are more susceptible to respiratory depression; use with caution and in reduced doses in this age group
  • Children 1-6 years: 4 mg/dose
  • Children 7-12 years: 8 mg/dose
  • Adolescents: 15 mg/dose
Monitoring and Follow-Up

If intermittent testicular torsion is suspected and the examination was normal, follow up in 7 days (sooner if the pain recurs) and do another complete examination.

Referral

Medevac as soon as possible. This is a surgical emergency.

For those with suspected intermittent testicular torsion, refer to a physician as a urology referral is often warranted.

Sources

Internet addresses are valid as of February 2012.

Books and Monographs

  • Behrman RE, Kliegman R, Jenson HB. Nelson's essentials of pediatrics. 17th ed. Philadelphia, PA: W.B. Saunders; 2002.
  • Berkowitz CD. Pediatrics: A primary care approach. Philadelphia, PA: W.B. Saunders; 2000.
  • Bickley LS. Bates' guide to physical examination and history taking. 7th ed. Baltimore, MD: Lippincott Williams & Wilkins; 1999.
  • Cash JC, Glass CA. Family practice guidelines. Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
  • Cheng A, Williams B, Sivarajan B (Editors). The Hospital for Sick Children handbook of pediatrics. 10th ed. Toronto, ON: Elsevier Canada; 2003.
  • Gray J (Editor-in-chief). Therapeutic choices. 4th ed. Ottawa, ON: Canadian Pharmacists Association; 2003.
  • Hay WW, Hayward AR, Sondheimer JM. Current pediatric diagnosis and treatment. New York, NY: McGraw-Hill; 2000.
  • Karch AM. Lippincott's 2002 nursing drug guide. Philadelphia, PA: Lippincott; 2002.
  • Pilla NJ, Rosser WW, Pennie RA, et al. Anti-infective guidelines for community acquired infections. Toronto, ON: MUMS Guidelines Clearing House; 2001.
  • Prateek L, Waddell A. Toronto notes -- MCCQE 2003 review notes.19th ed. Toronto, ON: University of Toronto, Faculty of Medicine; 2003.
  • Robinson DL, Kidd P,Rogers KM. Primary care across the lifespan. St. Louis, MO: Mosby; 2000.
  • Schwartz WM (Editor). The five minute pediatric consult. Baltimore, MD: Williams & Wilkins; 1997.
  • Strange GR (Editor). APLS -- The pediatric emergency medicine course manual. 3rd ed. Elk Grove Village, IL: American College of Emergency Physicians and American Academy of Pediatrics; 1998.
  • Uphold CR, Graham MV. Clinical guidelines in family practice. 4th ed. Gainesville, FL: Barmarrae Books; 2003.
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