Pediatric Primary Care: Practice Guidelines for Nurses, 2nd Ed.

CHAPTER 27

Genitourinary Disorders

Shelly J. King

I. MALE GENITALIA DISORDERS

Absent testicle, 752.59

Hypospadias, 752.61

Congenital adrenal hyperplasia, 255.2

Intersexuality, 752.7

Cryptorchidism, 785.51

Retractile testicles, 752.52

Disorders of male genitalia, 608.9

 

A. Cryptorchidism.

B. Etiology/incidence.

1. Cryptorchid testes can be absent, undescended, ectopic.

2. Can be result of chromosomal, hormonal, anatomic factors.

3. Majority (about 80%): palpable, are undescended or ectopic testes. Retractile testes: also palpable, sometimes misdiagnosed as undescended. Nonpalpable (20%) can be intra-abdominal, inguinal, absent testes.

C. Occurrence.

1. Most common male congenital anomaly, affects nearly 1% of term infants.

D. Clinical manifestations.

1. Risk of cryptorchidism increases in premature infant.

2. Bilateral nonpalpable testes or cryptorchid testes associated with hypospadias should be evaluated at birth for life-threatening intersex conditions such as congenital adrenal hyperplasia.

3. Parents may note retractile testicles in scrotum intermittently, especially after warm bath. Retractile testes are associated with an overactive cremasteric reflex. When examined they can be placed in the scrotum and will remain there for a short time after released. If they retract immediately they should be considered undescended.

4. In case of absent testicle, contralateral testicle may be larger than expected.

E. Physical findings.

1. Often helpful to have child in cross-legged sitting position for exam.

2. Retractile testes can be placed into scrotum, remain there for short period.

3. Nonpalpable testes maybe ectopic, found in femoral or perineal regions.

4. Scrotum may be flat/underdeveloped on affected side.

5. Larger than expected testicle may represent absent or nonfunctioning testicle on contralateral side.

F. Diagnostic tests.

1. Unilateral or bilateral palpable testes: No diagnostic testing indicated.

2. Bilateral nonpalpable testes or unilateral nonpalpable testes associated with phallic abnormality: Evaluate with karyotype, endocrine testing, appropriate radiographic studies.

a. Human chorionic gonadotropin (hCG) stimulation test differentiates between anorchia and undescended testicles.

b. hCG can stimulate testosterone production in functioning testes and can also result in testicular descent.

G. Differential diagnosis.

Interse. conditions, 752.7

Retractile testes, 752.52

1. Retractile testes.

2. Intersex conditions.

H. Treatment.

1. If at 6 months of age testes remain undescended, intervention is necessary.

a. Type of treatment depends on testes' location, patient's age, association with other anomalies.

b. Reasons for treatment: reduced fertility, risk of tumor formation, trauma, torsion, repair of commonly associated defects such as inguinal hernia, psychological factors related to body image.

2. Placing testes into scrotum does not decrease risk of testicular cancer but does provide easy exam for early detection. Risk of testes cancer in cryptorchid male is 1 in 2000.

3. Orchiopexy or open surgery fixes testicle in scrotum and repairs hernia if needed. Laparoscopy can be used to locate nonpalpable testes or blind-ending vessels. There is also laparoscopic approach to orchiopexy.

4. Hormone administration is not as successful as surgical approach but good option in high-risk patients and/or patients who have testes found in high scrotum or at external inguinal ring.

I. Follow up.

1. After surgery, examine incisions at 2–4 weeks, 4–6 months postop.

2. Hormonal therapy: Examine at 1 month, 6 months post-treatment (higher risk of reascension).

3. Yearly exam important; patient should be taught self-exam at puberty. Can be performed by local medical provider or pediatric urologist.

a. Asymmetry of testes needs further evaluation.

4. Retractile testes should be evaluated annually for possible ascension.

J. Complications.

Testicula. atrophy, 608.3

1. Testicular atrophy is rated most serious complication of orchiopexy.

K. Education.

1. All males need to be taught self-scrotal exam at puberty. Especially important with history of undescended testicle due to increased risk of cancer.

2. Prior to puberty, annual exam should be done. Scrotal pain needs to be evaluated immediately to rule out risk of testicular torsion, trauma, epididymitis, torsed testicular appendage.

II. HYDROCELE

Hernia, 553.9

Scrotal swelling, 608.86

Hydrocele, 603.9

Processus vaginalis, 616.1

Intersexuality, 752.7

 

A. Etiology.

1. Occurs when processus vaginalis (channel that allows testicle to move from abdomen to scrotum during development) remains patent.

2. Difference between hernia and hydrocele is size of patent processus vaginalis and its contents.

a. Narrow channel only allows fluid from peritoneal cavity to pass, resulting in hydrocele.

b. Inguinal hernia: much wider, can allow both fluid and intestinal contents to pass.

B. Occurrence.

1. About 80% of infants are born with patent processus vaginalis; by end of first month of life, decreases to about 60%.

2. By 18–24 months of age, only 20–30% remain.

3. Rare in females: 6 males to 1 female.

C. Clinical manifestations.

1. Females: rare, usually presents with soft bulge in labia or inguinal canal.

a. Bulge can represent ovary or hernia.

b. Intersex conditions (especially testicular feminization): evaluate in female.

2. Males: parents complain of scrotal swelling in one or both sides. Can be continuous or intermittent; size can fluctu1ate.

a. Parent may describe bluish hue to scrotum, often small in size in morning and growing larger during day as fluid accumulates.

b. History is very important because may not be present at time of exam.

D. Physical findings.

1. Hydroceles typically transilluminate with penlight to scrotum.

2. Palpate testicle; if testicle cannot be palpated, can be seen by transillumination. If testes not seen or palpated, need scrotal ultrasound to differentiate.

3. Classified as communicating (patent processus vaginalis) or noncommunicating. Almost all congenital hydroceles are communicating. Noncommunicating hydroceles do not fluctuate in size.

4. Condition rarely painful unless associated with hernia that becomes incarcerated.

E. Diagnostic tests.

1. If any concern regarding testes, ultrasound imaging is indicated.

F. Differential diagnosis.

Ectopic testes, 752.51

Inguinal hernia, 550.9

Epididymitis, 604.9

Retractile testes, 752.52

1. Inguinal hernia.

2. Epididymitis.

3. Retractile testes.

4. Ectopic testes.

5. Absent testes.

G. Treatment.

1. Generally safe to watch hydroceles until 18–24 months. After that age spontaneous resolution is uncommon.

2. Earlier surgical intervention is indicated if hydrocele is large or associated with hernia secondary to increased risk of incarceration. Any abnormality of testes requires evaluation by scrotal ultrasound and could lead to earlier surgical intervention.

H. Follow up.

1. Child younger than 18 months of age should be examined every 6 months. If no change, no intervention indicated until 18–24 months.

2. If hydrocelectomy is performed, see patient 4 weeks postop to evaluate incision and scrotum. If exam is normal, can return to routine annual exam with healthcare provider.

I. Complications.

Hydrocele, 603.9

Testicular atrophy, 608.3

 

Incarcerated hernia, 552.9

Processus vaginalis, 616.1>

 

1. Complications from hydroceles are rare.

2. Risk of incarcerated hernia in patients with wide patent processus vaginalis.

3. Postoperative complications are rare; include recurrent hydrocele, testicular atrophy, lysis of vas deferens.

J. Education.

1. Although hydroceles and hernias are not really associated with increased risk of testicular cancer, discuss importance of self-scrotal exam.

2. Teach parents importance of regular exam during observation period.

3. If any scrotal pain, child needs to be seen immediately.

III. EPIDIDYMITIS

Chlamydia, 079.98

Neisseria gonorrhea, 098

 

Disorders of male genitalia, 608.9

Neurogenic bladder, 596.54

 

Dysuria, 788.1

Orchitis, 604.9

 

pididymitis, 604.9

Testicular torsion, 608.2

 

Exstrophy, 753.5

Urethral discharge, 788.7

 

Imperforate anus, 751.2

Torsed appendix testes, 608.2

 

A. Etiology.

1. Epididymitis refers to edema, irritation of epididymis or lining of testicle.

2. Can occur from infectious/inflammatory cause.

3. Can be difficult to distinguish epididymitis from testicular torsion because both can be quite painful.

4. Can be sexually acquired; Neisseria gonorrhoeae and Chlamydia are common pathogens.

5. Can be related to genitourinary abnormalities or urethra manipulation.

6. Rarely associated with heavy lifting or straining that result in efflux of urine into vas deferens. If urine is infectious, then bacterial epididymitis can occur; if not, chemical inflammation develops.

B. Occurrence.

1. Rare in children before puberty unless child has genitourinary abnormality.

2. More commonly occurs in sexually active adolescents.

C. Clinical manifestations.

1. Most likely to occur in postpubertal male and very young males.

2. Those with imperforate anus, exstrophy, neurogenic bladder, any conditions requiring intermittent catheterization are more prone to this type of infection.

D. Physical findings.

1. Include sexual history in postpubertal male.

2. Urethral discharge may be present.

3. Often slow onset of pain that continues to become more severe.

4. May have dysuria and see blood or discharge in urine.

5. Physical exam yields swollen and inflamed scrotum.

6. May complain of tenderness along epididymis.

7. If testicle is tender and swollen, may also have orchitis.

8. Up to 33% may be febrile.

E. Diagnostic tests.

1. Urine culture and urinalysis may be positive or negative for bacteria. If positive then X-ray evaluation by voiding cystourethrogram (VCUG) and renal-bladder ultrasound is indicated.

2. Scrotal ultrasound with Doppler flow is useful in differentiating epididymitis from testicular torsion. Ultrasound will show enlarged epididymis with increased blood flow unless edema is so severe it results in ischemia. May also show enlarged testicle with increased low flow in orchitis.

F. Differential diagnosis.

Bacterial epididymitis, 604.9

Torsion of testicular appendage, 608.2

 

Chemical epididymitis, 604.9

Urinary tract infections, 599

 

Testicular torsion, 608.2

Orchitis 604.9

 

Henoch-Schönlein purpura

   

  inflammatory vasculitis, 287

   

1. Testicular torsion.

2. Chemical epididymitis.

3. Bacterial epididymitis.

4. Torsion of testicular appendage.

5. Urinary tract infection (UTI).

G. Treatment.

1. Start 2 weeks of appropriate broad-spectrum antibiotic while cultures are pending. If necessary, change appropriately when cultures are final.

a. Children not sexually active: cephalexin: 40 mg/kg/day in 2 divided doses. Can also use:

• Ampicillin: 50 mg/kg bid.

• Trimethoprim-sulfamethoxazole (TMP-SMX): older than 2 months of age: 4 mg/kg and 20 mg/kg bid.

• Ciprofloxacin: 15 mg/kg bid postpuberty. Quinolone clinical trials are evaluating the safety and efficacy of use in children. Some clinical situations may warrant off-label use.

2. Ibuprofen for several days will help decrease inflammation, pain.

3. Scrotal support and elevating scrotum will help resolve edema.

4. Limited activity for 2–3 days.

5. Application of heat/cold compresses help reduce pain and edema.

6. If pain and edema are severe or not responding to treatment, consider IV antibiotics. Prolonged infection can result in damage to epididymis.

7. Identified STD should be treated with appropriate antibiotic regimen.

H. Follow up.

1. If pain increases, see patient immediately.

2. If condition is resolving, follow up in 2 weeks with repeat ultrasonography.

3. If positive urine cultures, a VCUG and renal-bladder ultrasound should be done. Increased likelihood of genitourinary abnormalities in males with positive urine cultures. Prophylactic antibiotics should be given until radiographic evaluation is complete (see UTI section).

I. Complications.

1. Possible damage to vas deferens, epididymis with recurrent or untreated infection.

J. Education.

1. Preventive education especially when epididymitis is associated with sexually transmitted infections (STIs).

2. Signs/symptoms of testicular torsion and acute scrotum indicate need for immediate attention by medical professional.

3. Genitourinary abnormalities can be associated with urinary infections so follow up with necessary testing.

IV. HYPOSPADIAS/CHORDEE

Disorders of male genitalia, 608.9

 

Hypospadias, 752.61

 

Chordee, 607.89

 

A. Etiology/incidence.

1. Cause of hypospadias is unknown; genetic link is suspected (many families with multiple occurrences).

2. Hypospadias is a congenital anomaly in which urethral meatus is ectopic; it is located on the undersurface of the penis any place between the glans and the scrotum.

3. Spectrum defect ranging from mild to severe, depending on degree of chordee (bend of penis), location of urethral opening. Mild forms can be found during newborn circumcision; stop circumcision–foreskin used to repair defect.

B. Occurrence.

1. Occurs in 1/250 of males in United States, 1/100 if immediate family history.

C. Clinical manifestations.

1. Difficult for older child to stand to urinate.

2. If associated with chordee, future intercourse may be difficult.

3. Parental anxiety/guilt common with genital malformation.

D. Physical findings.

1. Urethral opening lies on undersurface of penis.

2. Degrees of hypospadias: distal shaft refers to opening being closest to natural location.

a. As opening gets closer to scrotum, condition becomes more severe.

b. Referred to as midshaft, penoscrotal (located at penoscrotal junction), and perineal (located just beneath scrotum).

3. Chordee or bend of penis is often present.

4. Foreskin typically seen only on dorsal side of penis, gives “hooded” appearance.

5. Penile glans has spade-like appearance and cleft/blind-ending pit may be seen at location where meatus would normally reside.

6. Cryptorchidism may be associated.

E. Diagnostic tests.

1. Rarely necessary with hypospadias.

2. Early referral to experienced pediatric urologist important: Allay fears about child's masculinity, opportunity to assess for intersex disorders (uncommon but considered with severe hypospadias and hypospadias associated with cryptorchidism). 3. In some of more extensive cases, urinary tract will need to be evaluated.

F. Differential diagnosis.

Intersexuality. 752.7

1. Intersex disorders.

G. Treatment.

1. Referral to pediatric urologist as soon after birth as possible (reassure parents after surgical intervention child's potency/fertility no longer affected; makes it easier to discuss problem with other family members).

2. More than 200 surgical techniques described for hypospadias repair.

a. Goals same in each repair; cosmetically normal-appearing penis, straight with urethral meatus at tip. Repairs are performed in healthy males as early as 6 months of age.

b. Patient should be able to stand to void.

c. Selected cases may require preadministration of testosterone to enhance blood supply to genitalia.

d. Most surgery is done on outpatient basis.

e. Many approaches to postoperative dressing. Absorbable sutures are used in repairs, will not need to be removed.

f. Stent may be left through urethra to drain bladder while urethra heals. Nonabsorbable suture may be used to hold stent in place, will need to be removed about 1 week postop.

H. Follow up.

1. See in 1 week to inspect incision, remove any dressings, stent if necessary.

2. See again 2–3 months later, after majority of edema is resolved, to ensure penis is straight, meatus is widely open.

3. Some surgeons schedule visit after toilet training to visualize normal voiding stream; others see child after puberty to discuss surgery, alleviate fears.

4. If ever difficulty voiding or UTI, patient should be seen immediately by pediatric urologist.

I. Complications.

GU hematoma, 863.8

Urethral stricture, 598.9

 

Meatal stenosis residual chordee, 607.89

Urethrocutaneous fistula, 599.1

 

Urethral diverticulum, 599.2

Wound infection, 958.3

 

1. Experienced hypospadiac surgeon is important to minimize complications.

2. Rate of complication varies according to severity of defect.

a. Early postoperative complications: uncommon but include wound infection, urethrocutaneous fistula, hematoma.

b. Late complications: urethral stricture, meatal stenosis residual chordee, urethral diverticulum.

c. If secondary procedure necessary, not performed until tissues well healed–approximately 6 months after initial repair.

J. Education.

1. Important to educate newborn-care providers not to circumcise if any penile defects: Foreskin is used for repair.

2. Understanding defect and its correction can alleviate parental fears. Reassure them child's masculinity not affected; structural problem that can be corrected surgically.

3. Patient must understand potential for complications. Any difficulty voiding or urinary tract infection need follow up with pediatric urologist.

V. FEMALE GENITALIA DISORDERS

Disorders of female genitalia, 629.9

  Incontinence, 788.31

 

Dysuria, 788.1

  Labial adhesions, 752.49

 

A. Etiology.

1. Labial adhesions are fusion of labia minora, occur as result of vulvar irritation, lack of estrogen.

2. Possible causes: chronic inflammation, irritation secondary to infection, trauma, incontinence.

B. Occurrence.

1. Primarily in girls 3 months to 6 years of age.

C. Clinical manifestations.

1. Dysuria and incontinence are common complaints when efflux of urine is blocked and urine is trapped behind adhesions.

2. Toilet-trained girls may complain of postvoid dribbling. Maternal estrogens seem to prevent adhesions in newborns.

D. Physical findings.

1. Labial adhesions appear as thin film that begins posteriorly and advance anteriorly.

2. In more severe cases, cannot see vaginal introitus or urethral meatus.

3. Presence of scarring that deviates from midline or more dense adhesions should raise question of repeat trauma/sexual abuse.

E. Diagnostic tests.

1. None.

F. Differential diagnosis.

Intersexuality. 752.7

Sexual abuse, 995.53

1. Intersex conditions.

2. Sexual abuse.

G. Treatment.

1. Majority requires no treatment, resolve spontaneously.

a. Keep child clean and dry to prevent irritation and superficial infection.

2. More significant adhesions that present with dysuria and postvoid dribbling can be treated with hormone cream or lysis of adhesions.

a. Premarin cream: 0.625 mg applied with gentle pressure to the translucent midline twice a day for 10–14 days.

b. Betamethasone cream 0.05% bid can be used up to 4 weeks.

3. Lysis of thinned adhesions can be done in office after EMLA cream application.

4. More dense-appearing adhesions or those that have been broken down previously may be done more effectively and with less trauma in operating room. Critical to prevent readherence by applying barrier cream to previously attached tissues twice a day for 8–12 weeks.

H. Follow up.

1. No treatment: Follow up with each well-child check, may become more severe with time (best obtained by urethral catheterization).

2. If complaints of dysuria: Careful collection of urine specimen is important; it is difficult to collect valid specimen by voiding when adhesions are present (catheterization preferred).

3. Post-treatment: See patient 4–6 weeks later to ensure no reoccurrence.

I. Complications.

Urinar. tract infections (UTI), 599

1. Biggest risk is reoccurrence due to poor parental compliance with barrier cream placement after adhesions have been lysed.

2. If painful voiding, child may delay voiding, empty more poorly resulting in true UTIs.

3. Prolonged use of estrogen can result in development of secondary sex characteristics.

J. Education.

1. Importance of post-treatment management must be stressed to parents; most important in preventing further problems with adhesions. Sometimes difficult for parents, especially if child complains of discomfort when medication is applied.

2. Child should learn to void with legs widely separated to facilitate good bladder emptying and to keep labia separated during voiding.

3. If urine specimen necessary, take care to avoid contamination; done best by catheterization.

4. Parents understand length of Premarin treatment; possible side effects of prolonged or repeated use.

VI. PEDIATRIC URINARY TRACT INFECTIONS

Constipation, 564

Nausea, 787.02

 

Diarrhea, 787.91

Poor feeding, 783.3

 

Dysuria, 788.1

Suprapubic/urethral pain, 788

 

Fever, 780.6

Urinary frequency, 788.41

 

Flank pain, 789

Urinary tract infections, 599

 

Incontinence, 788.31

Vomiting, 787.03

 

Irritability, 799.2

   

A. Etiology.

1. Periurethral bacteria infect bladder, ureter, kidney. Escherichia coli most frequently identified pathogen.

B. Occurrence.

1. Fairly common: 2.4% of children yearly, majority are ascending.

2. Up to 6 months of age, more common in males than females, incidence of 2 cases per 100 live births. Uncircumcised males less than 6 months old have a tenfold increased risk for UTI development.

3. After 1 year of age, much more common in females.

4. Approximately 3% of toilet-trained females will develop infection.

a. Of children who develop infection, 17% will develop infection-related renal scarring.

b. Of those, 10–20% will have hypertension.

C. Clinical manifestations.

1. Symptoms of UTI in infants often difficult to recognize.

2. Usually generalized illness with fever, irritability, poor feeding, vomiting, diarrhea. Suspect when no other source for illness.

3. Older children complain of dysuria, suprapubic/urethral pain, urinary frequency, incontinence. Can also have fever, flank pain, nausea, vomiting if kidney is involved.

4. Foul-smelling urine, constipation (commonly associated, obtain stool history).

D. Physical findings.

1. Perform thorough exam.

2. May detect renal mass in infants with gross anatomic abnormalities such as obstruction or mass.

3. Costal-vertebral angle (CVA) tenderness seen while palpating flank of older children.

4. If dysuria is primary concern, perineal exam may show external irritation related to incontinence, vaginal voiding, labial adhesions.

5. Sometimes treated as UTIs: vaginitis and pinworms sometimes mistaken (because often present with dysuria).

6. Vaginal discharge: culture if present; may have suprapubic tenderness.

7. Males: scrotal exam to rule out epididymitis, especially in older males who may be sexually active.

a. Look for urethral discharge; culture if present.

b. UTIs younger than 6 months of age are very uncommon, need evaluation.

c. Abdominal exam may also yield large stool burden; constipation very common in children with UTIs.

E. Diagnostic tests.

1. Collecting urine specimen is very important in documenting infection. Four techniques for obtaining a specimen are listed in Table 27–1.

2. X-ray evaluation: infants, febrile UTIs, males, recurrent UTIs, children who are not toilet trained. Important that true infection is documented by catheterized culture when deciding what additional evaluation is necessary.

3. If criteria met, then VCUG and renal-bladder ultrasound are ordered to evaluate urinary tract.

a. Obstructions of urinary tract seen in 5–10%; 21–57% have vesicoureteral reflux.

• If tests are negative, no additional evaluation necessary unless further problems arise.

• If tests are positive, refer to pediatric urologist for evaluation, consultation, possibly treatment.

Table 27–1 Techniques for Obtaining a Specimen

Techniques

Use for specimen

Drawbacks

Bagged specimen (baggy attached to perineum)

Helpful in ruling out UTI

If positive, catheter specimen needs to be obtained (false positives: 90%, especially if left on for 20 minutes)

Clean-catch midstream

Better collection; provides results of multiple organisms of small colony counts that are suggestive of contamination

Difficult for children (parents have a hard time cleaning, separating labia in girls); urine often hits perineum before reaching the cup

Catheterized specimen

Most widely accepted technique for determining true UTIs

Some offices not set up to catheterize children

Urinalysis

Provides information on leukocytes and nitrates (positive nitrates is highly predictive of infection), urine culture should be sent to assess colony count, pathogens present, appropriate antibiotic treatment

 

Suprapubic aspirate

Most reliable

Rarely utilized because of anxiety associated with placing needle through abdominal wall and into bladder; can be threatening to child, parent/care provider

4. In case of febrile child, serum chemistries can identify elevation in creatinine or BUN, may implicate urinary tract. CBC with elevated WBC count can indicate bacterial infection.

F. Differential diagnosis (see Table 27–2).

G. Treatment.

1. Goals: Prevent renal damage, urosepsis, future infections.

a. How goals are accomplished varies according to severity and age of patient.

Table 27–2 Urinary Tract Infections

Febrile UTIs

Afebrile UTIs

Obstruction of urinary tract, 599.6

Perineal irritation, 709.9/chemical irritation

Renal mass, 593.9

Labial adhesions, 752.49/vaginal voiding

Urosepsis, 599

Pinworms, 127.4

Pelvic inflammatory disease, 614.9

Abuse (rare)

Sexually transmitted infections

Hematuria, 599.7/hypercalciuria, 2 75.4

2. Infants who appear systemically ill or are less than 3 months of age should be hospitalized.

a. Parenteral broad-spectrum antibiotics, usually aminoglycoside (e.g. gentamicin), ampicillin. Third-generation cephalosporins can also be used.

b. Some situations can be managed with outpatient therapy:

• Parenteral ceftriaxone if child is taking fluids well, parents are reliable enough to contact provider if condition changes.

• Some older children can be managed as outpatients with cephalosporins, penicillins, sulfonamides. Antibiotic treatment is 7–10 days.

• Parent involvement is very important when managing patients outside hospital; provider must have confidence in family.

c. Continue parenteral treatment until culture, sensitivity returns and clinical picture is improving, then place child on appropriate oral antimicrobial.

d. Quinolones are not yet approved for pediatric UTI management but clinical trials are evaluating the safety and efficacy in children. Some clinical situations may warrant limited off-label use.

e. Nitrofurantoin is not a good antimicrobial in a systemically ill patient, does not attain high serum concentrations.

3. Lower tract or bladder infections are referred to as uncomplicated UTI.

a. Children: 3- to 5-day course of oral antimicrobials.

b. Nitrofurantoin: good option, provides high urinary concentration (other agents used: sulfonamides, cephalosporins, penicillins).

c. Antibiotic prophylaxis: maintained after infection is treated to prevent infection from reoccurring before completion of X-ray evaluation. May need to be continued after X-ray evaluation: vesicoureteral reflux, urinary tract obstruction, immunosuppression, recurrent UTIs, or less than 6 monthss of age.

• Nitrofurantoin: 1.2–2.4 mg/kg or TMP-SMX 2 mg/kg of trimethoprim once a day are common choices.

• Cephalosporins (such as cephalexin) or ampicillin: 25% treatment dose daily.

• Nitrofurantoin: Do not use until older than 1 month of age.

• TMP-SMX: Do not use until older than 2 months of age.

• Both Keflex and ampicillin can be used in newborn.

d. Treatment must also include good oral intake of fluids, encouraging toilet-trained patient to void more frequently.

e. If associated constipation, this must also be addressed.

• Prevents good urinary evacuation.

• Provides good medium for microbial growth.

• Dysfunctional elimination syndrome (poor emptying of bowel and bladder) is hallmark of UTIs in toilet-trained patients.

f. Educate parent in treatment of problem.

• Urination on timed schedule usually every 2 hours with techniques for relaxation of external urinary sphincter.

• Voiding to completion with each attempt is vital to preventing further infections. Have child sit comfortably on the toilet with legs widely separated and feet supported on a footstool if they don't reach the floor. Some children sit backward on the toilet.

• Stool softeners are often necessary while working on dietary measures to prevent constipation.

g. Perineal irritation.

• Scented soaps, bubble baths may irritate urethra, cause burning that results in disrupted urinary stream, poor emptying of bladder; discontinue in patients with recurrent UTIs.

• Covering perineum with barrier cream helps prevent burning caused from irritation especially with incontinence associated with infection.

• Vulvovaginitis can be treated with baking soda sitz bath (3 tablespoons) in a shallow tub bath daily for 1 week.

H. Follow up.

1. Follow-up culture to prove infection has resolved.

2. If X-ray evaluation is positive or if infections are recurrent: urology consult preferably with pediatric urology group. Specialist can do postvoid ultrasound/other treatments to help patient learn to empty more effectively, correct any structural abnormalities if necessary.

3. More thorough education of problems associated with infection will help family and provider.

I. Complications.

Chronic cystitis, 595.2

Incontinence, 788.31

Hypertension, 401.9

Loss of renal function, 593.9

1. Serious risks, warrants effective management.

a. Renal scarring, loss of renal function are most serious complications.

b. Hypertension can result from renal scaring.

c. Chronic cystitis can result in poor functional use of bladder, sometimes incontinence.

J. Education.

1. Understand signs/symptoms of UTIs and need for treatment/evaluation.

2. Importance of daily antibiotic and/or stool softener (if prescribed); easy to forget to take medication.

3. Understand dysfunctional elimination and its treatment, primarily need to empty bladder frequently to completion, to avoid constipation.

4. Follow up critical in management of UTIs due to risk of renal sequelae.

VII. HEMATURIA

Alport syndrome, 759.89

Hemolytic uremic syndrome, 283.11

Anatomic abnormalities, 759.9

Hypercalciuria, 275.4

Benign familial hematuria, 599.7

Lupus erythematosus, 710

Calculi, 592.9

Purpura, 287

Disorders of renal parenchyma, 588.9

Sickle cell nephropathy, 583.81

Glomerulonephritis, 583.9

Urethralgia, 788.9

Hematuria, 599.7

Urinary tract infection, 599

A. Etiology/incidence.

1. Gross hematuria (blood visible to naked eye) can originate from upper/ lower urinary tract.

2. Causes: variable; include trauma, UTI, calculi, disorders of renal parenchyma, glomerulonephritis, Alport syndrome, hypercalciuria, benign exercise-induced hematuria, anatomic abnormalities, hemolytic uremic syndrome, sickle cell nephropathy, Henoch-Schönlein purpura, Goodpasture disease, lupus erythematosus, medication toxicity/chemotherapy, urethralgia, viral bladder infections, STDs (in postpubertal child).

B. Occurrence.

1. Common in children (unlike adults): rarely associated with neoplasm (1%).

2. Microscopic hematuria found on routine health exam by dipstick urinalysis in 0.5–2% of school-aged children.

C. Clinical manifestations.

1. History important in determining diagnosis.

a. Urinary frequency, fever, dysuria may indicate infection, most common cause of blood in school-aged child's urine.

b. May describe recent trauma.

c. Blood in other sites (i.e., sputum/stools) may indicate blood dyscrasia.

2. Family history: familial diseases such as hypercalciuria, Alport syndrome, calculi, structural anomalies.

3. Hemolytic uremic syndrome, one of most common causes of acute renal failure in children: preceded by gastroenteritis, bloody diarrhea.

a. Question child regarding any joint pain, edema, tenderness.

b. Any recent cold, upper respiratory symptoms? Sore throat/skin infection present?

4. Acute nephritic syndrome: associated with gross hematuria, edema, hypertension, renal insufficiency.

a. Post-streptococcal glomerulonephritis occurs 7–14 days after onset of strep infection.

b. Winter months: commonly associated with strep pharyngitis.

c. Summer months: more likely to be skin infections.

5. When bleeding occurs, urine color is important.

a. Brown/cola-colored urine: more likely from kidney.

b. Red/pink urine: more likely from bladder.

c. Red blood spotting at end of urinary stream/in underwear: most likely from urethra.

D. Physical findings.

1. Full-body exam to look for:

a. Abdominal or renal mass.

b. Presence of abdominal, CVA tenderness.

2. Check child's underwear for blood, perineum for signs of trauma.

3. Assess joints for edema, inflammation, tenderness.

4. Edema of face, hands, or feet.

5. Assess for signs of upper respiratory infection, pharyngitis, or other illness.

E. Diagnostic tests.

1. Urinalysis may reveal infection or proteinuria.

2. Laboratory analysis: formal urinalysis, culture if thought to be infection; urine calcium/creatinine ratio; urine protein/creatinine ratio.

3. Serum studies: CBC with differential and platelet count, complete metabolic panel, anti-streptolysin enzyme (ASO) or streptozyme, antinuclear antibody (ANA) and C3.

4. Skin or throat cultures when appropriate.

5. Sickle cell screen in all African American patients.

6. Coagulation studies with history of bleeding from other sites.

7. Cystoscopy: only if persistent gross hematuria.

F. Differential diagnosis.

Hematuri. (benign, essential, idiopathic), 599.7

Idiopathic hypercalcemia, 275.42

1. Pseudohematuria.

2. Idiopathic hypercalcemia.

3. Extrarenal hematuria.

4. Exercise-induced hematuria.

G. Treatment.

1. Systemically ill child with gross hematuria: Admit while being evaluated.

2. If elevated ASO and low C3 (hypocomplementemia), refer to nephrologist to rule out/treat nephritis.

3. If abnormal ultrasound, referral to urologist to determine presence of structural anomalies.

4. With UTIs, refer to urologist and consider VCUG.

5. Abnormal ANA results, elevated ANA: consult rheumatology, nephrology; commonly associated positive crithidia may indicate lupus erythematosus.

6. Other blood dyscrasias: consult hematology.

7. Elevated serum creatinine, hypertension, peripheral edema, abnormal calcium/creatinine ratio, protein/creatinine ratio: refer to nephrologist. Renal biopsy/cystoscopy may be necessary to diagnose.

8. Urethralgia: hallmarked by blood at end of urinary stream or in underwear, can persist without negative consequence in child for years. Treatment is controversial: Some use antibiotics, but have not been proven effective.

9. If child develops hypertension or proteinuria, refer to nephrologist. Renal

10. biopsy may be indicated. 10. If chlamydia or gonorrhea is suspected:

a. Younger than 9 years of age: erythromycin 50 mg/kg/day qid (max 2 g/day).

b. 9–15 years of age: ceftriaxone 250 mg IM single dose followed by 7 days of doxycycline 200 mg/day bid.

c. Older than 15 years of age: azithromycin 1 g in 1 dose.

H. Follow up.

1. Determined by disease, usually done by appropriate specialist.

2. Urethralgia without significant symptoms and benign familial hematuria without proteinuria and hypertension: Monitor by checking urine and blood pressure every 6–12 months.

I. Complications.

Electrolyt. imbalance, 276.9

Renal failure, 586

1. Renal failure.

2. Significant electrolyte imbalance.

3. Follow up with specialist very important for children with these complications.

J. Education.

1. Parents must understand importance of having studies done and follow up with specialists.

2. If medications prescribed, how and when to give and possible side effects.

3. Know signs/symptoms of progressive renal disease: edema, hypertension, increasing blood in urine, proteinuria, UTI, lethargy, pallor.

VIII. PROTEINURIA

Cold exposure, 991.9

Hypertension, 401.9

Congestive heart disease, 428

Obstructive uropathy, 599.9

Edema, 782.3

Polycystic kidney disease, 753.12

Febrile illness, 780.6

Proteinuria, 791

Glomerulonephritis, 583.9

Pyelonephritis, chronic, 590.8

Hematuria, 599.7

Tubular necrosis, acute, 584.5

A. Etiology.

1. Renal insufficiency often associated with proteinuria.

2. Diagnosed by random urinalysis on well-child checkup or associated with serious illness.

3. Common causes of proteinuria include chronic pyelonephritis, renal scarring, febrile illness, glomerulonephritis, exercise induced, idiopathic, orthostatic, polycystic kidney disease, acute tubular necrosis, cold exposure, congestive heart disease, obstructive uropathy, pregnancy, drug induced, trauma.

B. Occurrence.

1. Positive screening by dipstick: approximately 10% of 8- to 15-year olds.

a. Dipstick finding considered positive if it is 1+ (30 mg/dL). False positives can occur with concentrated urine specimens; if specific gravity is 1.015, dipstick finding for protein needs to be higher than 2+.

2. If in doubt, look for other symptoms: hypertension, edema, hematuria.

3. Always best to confirm lower range and asymptomatic results by rechecking/confirming by protein-to-calcium ratio.

C. Clinical manifestations.

1. Varies with diagnosis.

2. Glomerulonephritis presents with hematuria and proteinuria.

a. ecreased glomerular filtration rate can result in sodium and water retention, oliguria, circulatory overload, edema, hypertension.

b. Chronic glomerulonephritis results in failure to thrive, slow growth, fatigue.

3. Postural or orthostatic proteinuria: usually discovered on well-child check.

a. Usually older than 8 years of age and totally asymptomatic.

b. Exercise-induced proteinuria is seen after vigorous exercise, resolves with 48 hours rest.

c. Febrile proteinuria resolves as temperature returns to normal.

4. Henoch-Schönlein purpura nephritis (a systemic vasculitis) presents with abdominal cramping, purpuric rash, joint pain.

a. Bloody diarrhea occurs in 50% of patients.

b. Hemolytic uremic syndrome, systemic lupus erythematosus can also present with purpura, inflammatory bowel.

c. Known history of renal disease or strong family history of renal compromise.

D. Physical findings.

1. Urinalysis shows proteinuria ranging from trace to 4+, microscopic/gross hematuria.

2. May be associated infection indicated by elevated urine WBC, nitrites.

3. Blood pressure may be elevated.

4. Edema (especially periorbital) may be present.

5. Patient complains of joint pain, stiffness. Joints swollen, inflamed on exam.

6. Complaints of dysuria or frequency: signs of infection, CVA tenderness, flank pain may indicate obstruction or pyelonephritis.

E. Diagnostic tests.

1. In nonacute setting: obtain protein-to-creatinine ratio.

a. If > 0.2, repeat; if still elevated, obtain 12- or 24-hour urine.

b. Supine and upright collection obtained to rule out orthostatic proteinuria. Nonpathologic proteinuria associated with posture, fever, or exercise usually yields results < 1 g/24 hours.

c. Renal ultrasound is normal.

2. Pathologic proteinuria results from glomerular, tubular disorders of kidney.

a. Protein-to-creatinine ratio is > 0.2, 24-hour urine results are = 3 g of protein in 24 hours.

b. Renal ultrasound can show infectious or obstructive nephropathy.

c. Complete metabolic panel, CBC with differential and platelets, ASO, C3, ANA help sort out the immunologic from the nephrologic causes.

d. Throat and/or skin cultures can identify post-streptococcal glomerulonephritis.

F. Differential diagnosis.

1. See Etiology.

G. Treatment.

1. Treatment is dependent on type and severity of proteinuria, obstructive uropathy can be repaired surgically.

2. Infectious uropathy: Treat with antibiotics.

3. Associated hypertension: may need short- or long-term treatment.

4. Urgent nephrology referral with edema and hypertension.

5. Systemically ill patients require hospitalization to determine cause.

6. If creatinine-to-protein ratio is > 0.2, refer to nephrology for further evaluation.

H. Follow up.

1. Follow up may be lifelong depending on cause.

2. Recheck asymptomatic proteinuria annually by dipstick analysis and blood pressure: If either is abnormal, referral or additional evaluation needed.

I. Complications.

Failur. to thrive, 783.41

Hypertension, 401.9

Renal failure, 584.9

1. Failure to thrive, renal failure, hypertension.

J. Education.

1. Know signs/symptoms of progressive disease process.

2. Ensure routine urinalysis remains part of well-child check so early evaluation and treatment can be done.

3. Follow nonpathologic proteinuria annually.

4. Close observation for pathologic proteinuria.

BIBLIOGRAPHY

Behrman RE, et al. Textbook of pediatrics. 17th ed. Philadelphia, PA: W.B. Saunders; 2004.

Gearhart JP, Rink RC, Mouriquand PD. Pediatric urology. Philadelphia, PA: WB Saunders; 2010.

Johnson KB, Oski FA. Oski's essential pediatrics. Philadelphia, PA: Lippincott-Raven; 1997.

Oneil JA, Jr., et al. Principles of pediatric surgery. 2nd ed. St. Louis, MO: Mosby; 2004.

Wein AJ, Kavoussi LR, Novick AC, et al. Campbell-Walsh urology. Philadelphia, PA: Elsevier; 2010.



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