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Home , Diurnal enuresis, Genitourinary system

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.

Table of Contents

INTRODUCTION...... 13–1 ASSESSMENT OF THE GENITOURINARY SYSTEM...... 13–1 History of Present Illness and ...... 13–1 Physical Examination...... 13–1 COMMON PROBLEMS OF THE GENITOURINARY SYSTEM...... 13–3 Glomerulonephritis...... 13–3 Hydrocele (Physiologic)...... 13–5 Prepubescent Vaginal Discharge...... 13–6 ()...... 13–8 Urinary Tract Infection...... 13–8 EMERGENCY PROBLEMS OF THE MALE GENITAL SYSTEM...... 13–11 Testicular Torsion...... 13–11 SOURCES...... 13–13

Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010

Genitourinary System 13–1

INTRODUCTION

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

ASSESSMENT OF THE GENITOURINARY SYSTEM

The genitourinary (GU) system may be affected by –– Change in colour or cloudy, foul-smelling urine congenital abnormalities, inflammation, infection, –– Abdominal, suprapubic, flank or back pain or other body systems or of the kidneys. tenderness –– Scrotal or groin pain HISTORY OF PRESENT ILLNESS –– Genital sores, swelling, discolouration AND REVIEW OF SYSTEMS –– Lack of circumcision –– Toilet-training problems Newborns and infants with urinary tract disorders and diseases may present with the following signs –– Irritability and symptoms:1 –– Poor feeding –– Pallor The following symptoms are associated with –– Fever nephrotic syndrome and glomerulonephritis: –– Jaundice –– Swelling (for example, ankles, around eyes) –– Seizures –– Headaches –– Dehydration –– Nosebleeds (an occasional symptom of –– Poor feeding hypertension, but nosebleeds also occur frequently –– Vomiting in normal children) –– Excessive thirst –– Hematuria –– Frequent –– Smoky or coffee-coloured urine –– Screaming on urination –– Decreased urinary output –– Poor urine stream –– Pallor –– Foul-smelling urine –– Weight gain –– Enlarged or bladder A complete history of the GU system should include –– Persistent diaper rash questions related to: –– Failure to thrive –– Sexual activity (for adolescents) –– Rapid respirations (acidosis) –– Problems related to inappropriate touching –– Respiratory distress by others (that is, sexual abuse) –– Spontaneous pneumothorax or pneumomediastinum Children must be asked such questions with sensitivity and without the use of leading questions. The parents The following are those most or caregiver can be asked about these topics directly. commonly associated with urinary tract infection (UTI) in children:2 PHYSICAL EXAMINATION –– Fever –– Enuresis (bed-wetting) VITAL SIGNS –– Incontinence (new onset) –– Temperature –– –– rate –– Hematuria –– Respiratory rate –– Frequency –– Blood pressure –– Urgency

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URINARY SYSTEM (ABDOMINAL –– Discharge at (distinguish poor hygiene EXAMINATION)3 from urethritis) For full details, see “Physical Examination” of the –– Inflammation of foreskin or head of penis abdomen in the pediatric chapter “Gastrointestinal (sign of balanitis) System”. Palpation:

INSPECTION –– Foreskin adherent at birth normally –– In 90% of uncircumcised male children, the –– Abdominal contour, looking for asymmetry foreskin becomes partially or fully retractable or distention (a sign of ascites) by 5 years of age4 –– Abdominal pulsations –– Inability to retract foreskin (phimosis) –– Peripheral vascular irregularities –– Inability of retracted foreskin to return to normal –– Masses position (paraphimosis)

PERCUSSION and –– Determine size Inspection: –– span (may be increased in glomerulonephritis) –– Scrotum may appear enlarged –– Ascites (dull to percussion in flanks when child –– Check penile and scrotal for any unusual is supine; location of dullness shifts when child lesions changes position) –– Check for edema (a sign of glomerulonephritis), –– Tenderness over costovertebral angle hydrocele (transillumination should be possible), hernia, or abnormal masses PALPATION Palpation: –– Size of liver and any tenderness because of –– Cremasteric reflex (absent in testicular torsion) congestion –– Testicular size, position, consistency, shape and –– Identify local areas of pain or mass lesions descent into scrotum –– Kidneys are often palpable in infants, the right –– Testicular tenderness: consider torsion or kidney being most easily “captured;” perform deep epididymitis (pain is actually in the epididymis, palpation to determine kidney size and tenderness not the ) (place one hand under the back and the other hand –– Swelling in inguinal canal: consider hernia or on the abdomen to try to “capture” the kidney hydrocele of spermatic cord between the hands) –– Mass in scrotum MALE GENITALIA For information about examining the adolescent male, Perform examination with the child supine and, see “Genitourinary and Male Genital Systems” in the if possible, in the standing position. adult clinical practice guidelines.

Penis4 FEMALE GENITALIA Inspection: The clinician must be sensitive regarding the genitourinary examination of the older female child. –– In the neonate, examination should focus upon Male providers should request the presence of a parent possible congenital anomalies or delegate during the examination. At the onset of –– Penile length the examination of the genitalia, explain to the patient –– Foreskin why examination of the area is needed and how it –– Location of the urethral meatus will be performed, including what instruments, if –– Scrotal anatomy (including rugae) any, will be used. –– Presence and location of the testes –– Child should be in supine frog-leg position for –– Presence of abnormal scrotal or inguinal masses examination –– Position of urethra (for example, , )

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–– Do not perform an internal vaginal examination in –– Ulcerative or inflammatory lesions a prepubescent child or an adolescent who is not –– Urethral irritation (sign of UTI) sexually active –– Vaginal discharge –– Spread labia by applying gentle traction toward –– Bleeding examiner and slightly laterally to visualize the –– Enlargement of vaginal orifice vaginal orifice –– History and observations should concur or may Inspection indicate sexual abuse –– Vulvar irritation For information about examining the adolescent female, see “Assessment of the Female Reproductive –– Erythema (in prepubescent girls, the labia normally System” in the adult chapter “ Women’s Health and appears redder than in adult women because the Gynecology”. tissue is thinner)

COMMON PROBLEMS OF THE GENITOURINARY SYSTEM

GLOMERULONEPHRITIS SYSTEMIC SYMPTOMS in which there is immunologic or toxic –– Anorexia damage to the glomerular apparatus of the kidneys. –– Periorbital edema It can occur acutely (acute glomerulonephritis) or –– Decreased urination it may have a chronic or insidious onset (chronic or –– Smoky or coffee-coloured urine progressive glomerulonephritis). –– Mild to severe hypertension –– ACUTE POST-STREPTOCOCCAL –– Fever GLOMERULONEPHRITIS5 –– Headache Acute post-streptococcal glomerulonephritis –– Lethargy (APSGN) is caused by glomerular immune complex –– Fatigue, malaise disease induced by specific nephritogenic strains –– Weakness of group A beta-hemolytic Streptococcus. It is the most common of the noninfectious renal diseases in –– Rash, impetigo childhood. APSGN can occur at any age but primarily –– pain affects early school-aged children, with a peak age –– Weight loss of onset of 6 to 7 years. It is uncommon in children under age 2. PHYSICAL FINDINGS The physical findings are variable and may include CAUSES the following: –– Usually secondary to previous streptococcal –– Edema (in about 85% of cases)6 infection (for example, of the throat or skin) –– Hypertension (in about 80% of cases)6 –– Follows pharyngitis or otitis by 1–3 weeks –– Hematuria (30% of children have gross hematuria)6 –– Lag time after skin infections is variable (can be –– Proteinuria up to 3 weeks) –– HISTORY –– Renal failure (to variable degree) –– Acute onset –– Congestive heart failure –– Usually history of pharyngitis or impetigo about –– Hypertensive encephalopathy (rare) 10 days before the abrupt onset of dark urine Edema, hypertension and hematuria are the most –– Acute phase lasts about 1 week common and most worrisome symptoms.

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DIFFERENTIAL DIAGNOSIS Pharmacologic Interventions –– Other forms of glomerulonephritis, which have None, unless complications develop. Treat many similar features (distinguished by laboratory complications only on physician’s instruction. tests, renal and other diagnostic methods) In patients with evidence of persistent infection –– Acute hemorrhagic cystitis (no edema, (that is, those with positive cultures), the underlying hypertension, renal failure; does involve dysuria, streptococcal infection can be treated with penicillin frequency, urgency) or erythromycin. –– Acute interstitial nephritis –– Antiglomerular basement membrane disease Monitoring and Follow-Up –– Cryoglobulinemia while Awaiting Transfer –– Nephritis, lupus –– Fluid restriction (to 60 mL/kg per day + urine losses) COMPLICATIONS –– Monitor blood pressure and vital signs –– Acute renal failure –– Daily weight –– Congestive heart failure –– Respiratory status –– Pulmonary edema –– Renal function –– Sepsis –– Monitor intake and output –– Hyperkalemia –– Watch for major life-threatening problems, –– Severe hypertension such as acute renal insufficiency with electrolyte –– Chronic renal failure abnormalities, fluid overload, pulmonary edema, congestive heart failure, acute hypertension DIAGNOSTIC TESTS Monitoring and Follow-Up over the Long Term The diagnosis is made on a clinical basis and is confirmed by the following tests: –– Will depend on cause and type of condition –– Post-streptococcal glomerulonephritis usually –– Urinalysis (hematuria, proteinuria) has no long-term sequelae, but other types –– Hemoglobin decreased (mild anemia) of glomerulonephritis may have long-term –– WBC count increased complications, including recurrence and chronic –– Recent throat swab positive for Streptococcus A renal failure infection –– Consulting specialist will provide instructions for surveillance MANAGEMENT Referral Goals of Treatment Medevac. –– Prevent, if possible, by early treatment of all streptococcal infections (skin and pharyngeal) CHRONIC OR PROGRESSIVE –– Prevent or treat complications GLOMERULONEPHRITIS5 Appropriate Consultation Chronic glomerulonephritis (CGN) is characterized by irreversible and progressive glomerular and Consult a physician immediately if you suspect tubulointerstitial fibrosis, ultimately leading to this disorder. a reduction in the glomerular filtration rate and retention of uremic toxins. In cases where CGN is not Nonpharmacologic Interventions associated with other diseases, it may go undetected While awaiting transfer: for years and be relatively asymptomatic until kidney –– Bed rest destruction produces a marked reduction in kidney function. Consequently, the disease is more common –– Fluid restriction (to 60 mL/kg per day in adolescents than in younger children. + urine losses) –– Sodium-restricted diet –– Correction of electrolyte imbalance

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HYDROCELE (PHYSIOLOGIC)7,8 Hydrocele of the spermatic cord may also be seen: A hydrocele is a collection of peritoneal fluid between –– Painless cystic swelling along the inguinal canal the parietal and visceral layers of the tunica vaginalis –– Swelling may transilluminate testis or along the spermatic cord. DIFFERENTIAL DIAGNOSIS Hyroceles are the most common cause of scrotal swelling and are relatively common in newborns, –– Enlargement of groin node appearing in approximately 6% of full-term male –– Trauma neonates. They rarely occur in infant girls, in which –– Cystic lesion they would present as a firm swelling in the groin. –– Hematoma Hydroceles may be communicating or –– noncommunicating. COMPLICATIONS CAUSES –– Slight increase in risk of inguinal hernia –– Testicular atrophy Communicating Hydroceles –– Epididymitis –– Usually develop as a result of failure of the processus vaginalis to close during development; DIAGNOSTIC TESTS the fluid around the scrotum is peritoneal fluid –– The diagnosis of hydrocele can be made by Noncommunicating Hydroceles physical examination and transillumination of the scrotum demonstrating a cystic fluid collection –– Fluid accumulation may be caused by infection, trauma, tumour, an imbalance between the MANAGEMENT secreting and absorptive capacities of scrotal tissues or an obstruction of the lymphatic or venous Goals of Treatment drainage in the spermatic cord –– Observe until condition resolves spontaneously –– This leads to a displacement of fluid in the scrotum, or surgical referral becomes necessary outside the testes –– Subsequent swelling leads to reduced blood flow Appropriate Consultation to the testes Consult physician in the following circumstances: HISTORY –– Diagnosis is unclear –– Painless swelling in scrotum –– There are signs of complications (for example, infection) –– Congenital or acquired –– There is an associated inguinal hernia –– Hydroceles that are present in newborns, whether communicating or noncommunicating, usually Nonpharmacologic Interventions resolve spontaneously by the first birthday, unless they are accompanied by an inguinal hernia –– Scrotal elevation –– Swelling may fluctuate in size –– Explain to parents or caregiver the pathophysiology of the defect PHYSICAL FINDINGS –– Reassure the parents or caregiver –– Should be able to palpate an upper border of –– Advise parents or caregiver to return to the clinic the swelling if the mass enlarges –– Soft, nontender fullness within the hemiscrotum Monitoring and Follow-Up –– Transillumination of the swelling should reveal a homogenous glow without internal shadows Reassess every 3 months until resolution occurs or –– Inguinal hernia may also be present referral becomes necessary. –– Examination of patients with hydroceles should include palpation of the entire testicular surface for findings of epididymitis, orchitis, testicular torsion, torsion of the testis or appendix epididymis, trauma or tumour as the primary etiology

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Referral –– Specific infection:Candida, Chlamydia, Neisseria Referral to a physician may be necessary if there gonorrhoeae, Trichomonas (uncommon), are signs of complications (for example, if there is bacterial vaginosis an associated inguinal hernia) or resolution does not If N. gonorrhoeae or Chlamydia is the cause of the occur when expected (by 1 year of age). discharge and the child is underage for consensual sex Surgical treatment is considered in the following (that is, < 16 years), sexual abuse must be considered. circumstances: HISTORY –– No signs of resolution by age 1 year (surgery may –– Various degrees of perineal discomfort or itching be delayed until age 2 or 3 in some circumstances) –– Vaginal discharge – note onset, quantity, colour, –– Hernias are associated with the hydrocele type, odour, consistency and duration –– Dysuria PREPUBESCENT VAGINAL –– Enuresis 9 DISCHARGE –– Frequency For vaginal discharge in adolescents, –– Recent , especially antibiotics see “Vulvovaginitis” in the adult chapter –– Associated illnesses (for example, URTI, skin “Communicable Diseases”. problems, pinworms) –– Hygiene DEFINITION –– Use of harsh soaps and bubble bath Physiologic discharge: –– Tight-fitting or nylon underwear or clothing –– Mucoid –– Possible sexual abuse –– Nonmalodorous PHYSICAL FINDINGS –– Seen in newborns and premenarchal girls (see “Tanner stage II and III” in the chapter, Do not perform a vaginal speculum examination “Adolescent Health”) or restrain the child. –– Normal vaginal secretions are often increased –– Suboptimal general or perineal hygiene midcycle in adolescents –– Signs of URTI or skin disease Any other discharge is a symptom of underlying problems. Labial Irritation –– Consider problems with perineal hygiene or local Vaginal discharge is uncommon in girls < 9 years old. chemical irritation (soaps, moisture) CAUSES AND ASSOCIATED ORGANISMS –– Candida infection –– Sexual abuse –– Poor hygiene (Escherichia coli) –– Moisture (especially resulting from synthetic fibre Marked Erythema underwear, tight clothing, wet swimsuits, obesity) Consider Candida infection –– Chemical irritants (bubble baths), local trauma –– Poor estrogenization is a common factor that Vaginal Discharge makes the vulvar tissues vulnerable to irritation and infection –– May be nonspecific –– Autoinoculation from associated upper respiratory –– Thick, white, cheesy: possibly Candida tract infection (URTI) (Haemophilus influenzae, –– Frothy, green: likely bacterial, Trichomonas group B Streptococcus) or skin infections –– Dark brown, foul smelling: possibly from (Staphylococcus) a foreign body –– Pinworms (E. coli) –– Foreign body (associated with E. coli) Foreign Body –– Other skin diseases affecting the genital area –– May be visualized better if child is in knee-chest (for example, eczema) position –– May be palpated while doing a rectal examination

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DIFFERENTIAL DIAGNOSIS Appropriate Consultation

Noninfectious Consult a physician if the child is febrile or has abdominal pain, or if you suspect sexual abuse. –– Poor hygiene Consider sexual abuse if you suspect nonexploitative –– Chemical irritation (for example, from bubble bath) sexual activity with a partner more than 2 years –– Foreign body older than themselves. Refer to the chapter “Child –– Trauma Maltreatment” for age-related definitions of child –– Atopic dermatitis abuse. Also refer to the chapter “Child Maltreatment” –– Psoriasis for provincial legislation on reporting maltreatment –– Seborrhea and abuse in children. –– Labial adhesions –– Systemic diseases (for example, Kawasaki Nonpharmacologic and or Crohn’s) Pharmacologic Interventions For poor hygiene Infectious –– Improve perineal hygiene –– Group A Streptococcus infection –– Avoid bubble baths –– Nonspecific bacterial infection –– Wipe from front to back, but avoid scrubbing –– Pinworms genitalia –– Candida (less common) –– Sexually transmitted infection (STI) (consider For foreign body sexual abuse) In an older child who can cooperate, remove the foreign body if visible and within easy reach; otherwise COMPLICATIONS consult a physician about options for removal. The complications depend on the underlying cause. amoxicillin (Amoxil), 50 mg/kg/day, divided tid, PO for 7–10 days while awaiting removal of foreign body –– Localized perineal irritation –– UTI For pinworms –– Abdominal pain (with pinworms or UTI) See “Pinworms” in Chapter 18, “Communicable –– Vaginitis Diseases”. –– Bleeding (from trauma) –– Labial adhesions For candidal infection clotrimazole 1% PV qd x 7 days DIAGNOSTIC TESTS For trichomonal infection If child is cooperative, attempt to swab vaginal orifice for age > 13 years, metronidazole (Flagyl), (using small, calcium alginate–tipped swab); avoid 2 g PO stat touching the hymenal edge. Swab for Chlamydia, for age < 13 years, consult a physician N. gonorrhoeae, culture and sensitivity and hanging regarding dosage drop, in that order. –– Urine for routine and microscopic analysis For bacterial vaginosis10 –– Urine for culture and sensitivity Preferred regimen: –– pH of vaginal secretions metronidazole (Flagyl, generics), 500 mg PO bid x 7 days Hormonal levels may be indicated in females with dry vaginal orifice. Consult physician or nurse practitioner Alternative regimen: if this is a finding. metronidazole (Flagyl, generics), 2 g PO stat

MANAGEMENT For STI Management depends on cause. Consult a physician, a certified sexual health nurse or a nurse practitioner if you suspect an STI Goals of Treatment in a preadolescent child. Refer to and follow the –– Identify and correct underlying cause

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“Canadian Guidelines on Sexually Transmitted COMPLICATIONS11 Infections” (available at: http://www.phac-aspc.gc.ca/ –– There is a clear association between voiding std-mts/sti-its/pdf/sti-its-eng.pdf). dysfunction and urinary tract infection (UTI) If the cause of the discharge is uncertain, send samples –– Voiding dysfunction may predispose children for culture and sensitivity and consult a physician or to recurrent UTI and renal injury nurse practitioner for therapeutic options. –– The risk of bladder colonization and UTI is Report as suspected sexual abuse all cases of increased in children with incomplete bladder gonorrhea and Chlamydia infection in girls where the emptying due to dysfunctional voiding or legal definition of sexual abuse is met.Refer to “Child underactive bladder Maltreatment” for age-related definitions of child MANAGEMENT abuse. Other cases of vaginitis may be reportable, depending on the circumstance. Goals of Treatment –– Rule out other causes (for example, infection) URINARY INCONTINENCE (ENURESIS)11,12 Nonpharmacologic Interventions Urinary incontinence is the uncontrolled leakage –– Moisture alarms of urine, which can be continuous or intermittent. –– Bladder training and related strategies: Incontinence is twice as common in boys as in girls.12 –– exercises for strengthening and coordinating muscles of the bladder and urethra CAUSES11 –– determining bladder capacity Night-time incontinence: –– drinking less fluid before sleeping –– developing routines for waking up –– Slower physical development –– urinating on a schedule (for example, –– Excessive output of urine during sleep every 2 hours) –– Anxiety –– avoiding caffeine or other foods or drinks –– Genetics that may contribute to incontinence –– Obstructive sleep apnea Daytime incontinence: Pharmacologic Interventions –– A complete urological review in consultation with a physician is required before is prescribed –– Infrequent voiding for urinary incontinence. –– Small bladder capacity –– Structural problems –– Anxiety-causing events URINARY TRACT INFECTION –– Drinks and foods that contain caffeine See also “Commons Problems of the ” in the adult chapter “Urinary and Male Genital HISTORY System”. –– Primary enuresis is wetting in a child who has Bacterial invasion of the genitourinary (GU) tract with never been dry for at least 6 months resulting infection. –– Secondary enuresis is wetting that begins after at least 6 months of dryness –– Cystitis: infection affecting only the lower GU tract (for example, the bladder) –– is wetting that usually occurs during sleep –– Pyelonephritis: ascending infection involving the upper GU tract (for example, the and –– Diurnal enuresis is wetting when awake, also kidneys) called daytime incontinence Urinary tract infection (UTI) is the most common DIFFERENTIAL DIAGNOSIS genitourinary disease in children. The prevalence –– Urinary tract infection 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

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 13–9 eight‑fold higher prevalence of UTI than circumcised –– Failure to thrive male infants. Female infants have a two- to four-fold –– Decreased activity, lethargy higher prevalence of UTI than male infants. This has been presumed to be the result of the shorter Younger Children (≤ 3 Years Old) female urethra. As for uncircumcised male infants, –– Abdominal complaints including pain the higher incidence is thought to be related to the –– Suprapubic tenderness mucosal surface of the uncircumcised foreskin being more likely to bind uropathogenic bacteria. In –– Fever – infants and children younger than 2 years uncircumcised boys, a possible partial obstruction can present with fever as the sole manifestation of 17 of the urethral meatus by a tight foreskin may be the UTI explanation for the higher incidence of UTI.13 An –– Frequency, urgency, dysuria, enuresis increased incidence of UTI is observed in adolescents, –– notably in those who are sexually active.14 –– Lack of circumcision in boys18

CAUSES Older Children (>3 Years)19 Bacterial invasion by one of the following –– May present with chronic urinary symptoms – organisms:14 incontinence, lack of proper stream, frequency, urgency, withholding maneuvers –– Escherichia coli in over 80% of cases15 –– Chronic –– Staphylococcus aureus –– History of previous UTI –– Enterococcus spp. –– Fever –– Klebsiella spp. –– Dysuria –– Proteus mirabilis –– Flank or back pain –– Pseudomonas spp. –– In sexually active girls, barrier contraception –– Haemophilus spp. with spermicidal agents predisposes to UTI –– Coagulase-negative staphylococci Predisposing factors: PHYSICAL FINDINGS –– Congenital GU tract abnormalities, for example, –– Fever (may be absent in simple cystitis) vesicoureteral reflux, short urethra (however, –– Suprapubic tenderness (in cystitis) most children with UTI have a normal GU tract) –– Tenderness of abdomen, flank and costovertebral –– Perineal fecal contamination because of inadequate angle (more likely with pyelonephritis) hygiene –– Hematuria –– Infrequent voiding or urinary stasis Be sure to assess hydration status. –– Perianal infections –– Sexual activity DIFFERENTIAL DIAGNOSIS Distinguish between cystitis and pyelonephritis. HISTORY The history depends on the child’s age. Infection of the Lower GU Tract (Cystitis) –– Urethral irritation (for example, bubble bath, Neonates and Infants16 scented soaps or ) –– Primarily nonspecific, non-urinary symptoms –– Urethral trauma –– May present with septicemia –– Diabetes mellitus –– Fever –– Masses adjacent to bladder –– Irritability (“colic”) –– Poor feeding Infection of the Upper GU –– Vomiting Tract (Pyelonephritis) –– Loose stools –– –– Jaundice (particularly in neonates) –– Pelvic inflammatory disease (PID) –– Hypothermia (Chandelier sign with bimanual examination) –– Tubo-ovarian abscess

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–– Appendicitis antibiotics. The decision about hospitalization –– Ovarian torsion depends on the child’s age and the severity of the clinical condition. COMPLICATIONS Goals of Treatment –– Recurrent UTI –– Sepsis, especially in neonates and infants –– Eradicate infection < 6 months of age –– Prevent recurrence –– Renal damage leading to adult hypertension, –– Identify underlying factors renal failure Appropriate Consultation DIAGNOSTIC TESTS Consult a physician for any of the following: Urinalysis for routine and microscopic examination –– Recurrent urinary tract infections where (midstream specimen for older children, catheter imaging (renal ultrasound or scan, voiding specimen for infants). cystourethrogram) may be required19 Bagged urine specimens are of no value in diagnosing –– Neonatal infections, for which medevac is a UTI in infants, even if positive. required; these are often associated with bacterial sepsis and require IV treatment –– White blood cells (WBCs) –– Suspected pyelonephritis, for which child may be –– Bacteriuria admitted to hospital (depends on age and severity –– Hematuria (blood in urine) of illness) –– Positive for nitrates (although UTI can occur with organisms that do not produce nitrate) CYSTITIS Urine for culture and sensitivity: Nonpharmacologic Interventions –– Preferably a first morning specimen; in infants, –– Increase rest if febrile use a clean catheter specimen –– Increase oral fluids to promote urine flow –– If multiple organisms present on culture, suspect contamination, not true infection Pharmacologic Interventions –– Complete blood count, serum creatinine and blood Do not treat as UTI unless results of appropriately cultures should be obtained if the child is febrile collected urine specimens support the diagnosis and systemically unwell (for example, positive for nitrates or WBCs). RADIOLOGIC EVALUATION20,21 Antibiotics: –– A renal and bladder ultrasound is the least invasive trimethoprim-sulfamethoxazole (TMP-SMX, method to visualize the kidneys and bladder, Septra and generics) and should be used primarily to screen for an The dose is calculated on the basis of the obstruction or abscess when resolution of UTI trimethoprim component not sulfamethoxazole symptoms is slower than expected –– Infants and young children with a UTI should contains TMP 40 mg / SMX 200 mg per 5 mL undergo radiologic imaging to examine the urinary tract for structural abnormalities if there is no trimethoprim-sulfamethoxazole: 5–10 mg TMP/kg significant improvement of symptoms after 2 days per day divided bid, PO for 7–10 days of antimicrobial therapy Consult a physician for choice of antibiotics if child is allergic to sulfonamides (“sulpha” drugs). MANAGEMENT The efficacy of long-term antibiotic prophylaxis of Lower GU infections (for example, cystitis) are recurrent UTI in children is not established.15 generally less severe and usually managed on an outpatient basis. Pyelonephritis is more severe Client Education: and may require hospital care for intravenous (IV) UTI can be prevented by: –– Proper toileting (wipe from front to back)

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–– Drinking plenty of fluids each day Monitoring and Follow-Up –– Encouraging cranberry juice to prevent urinary –– If treating as an outpatient, follow up in 24–48 22,23 tract infections. Cranberry juice is not effective hours. Review sensitivity of organisms to antibiotics 24 for the treatment of UTI when the results of urine cultures are available –– Urinating when the urge is felt, not holding it in –– If there is no response to oral antibiotics within –– Emptying the bladder after intercourse (sexually 48–72 hours or if symptoms are deteriorating, active teenagers) consult with a physician about changing the antibiotic or the need for IV antibiotic therapy PYELONEPHRITIS (SUSPECTED) Referral Adjuvant Therapy –– Medevac all infants under 4 months of age, and –– IV therapy with normal saline may be necessary for those who appear acutely ill (at risk of sepsis), children with pyelonephritis (before transfer) dehydrated or who are unable to tolerate oral –– Run at a rate sufficient to maintain hydration medications or fluids –– Older infants and children with suspected Pharmacologic Interventions pyelonephritis may require medevac, depending IV antibiotics may be started before transfer, on the on their clinical condition (for example, acute advice of a physician: illness [sepsis], dehydration or if unable to tolerate 100–200 mg/kg/day, divided q6h, IV/IM oral medications or fluids) –– Refer to a physician (for evaluation) any child and with culture-proven UTI who has been treated gentamicin (Garamycin), 5–7.5 mg/kg/day, divided on an outpatient basis q8h, IV/IM

EMERGENCY PROBLEMS OF THE MALE GENITAL SYSTEM

TESTICULAR TORSION25,26,27,28,29 remit suddenly. The pain occurs if a testis twists a little, and then returns back to its normal place on Abnormal twisting of spermatic cord and testis, which its own. compromises blood supply to these structures and results in ischemic injury and pain. Acute, severely Incomplete or partial testicular torsion is difficult to painful condition. diagnose because of its subacute presentation with nonspecific symptoms and signs. Torsion can occur at any age; however, it is most common in adolescence, with a peak at 14 years CAUSES of age. –– Torsion is usually spontaneous and idiopathic Testicular torsion is a medical emergency. If the blood (often occurs during sleep) supply to the testis is cut off for more than about –– Predisposing structural (genetic) defect (for six hours, permanent damage to the testis is likely example, inadequate fixation of testis to tunica to occur. vaginalis, bell clapper deformity) –– Occasionally caused by minor trauma to the groin PARTIAL OR INTERMITTENT –– Strenuous physical activity TESTICULAR TORSION30 –– Sexual activity or arousal Torsion is not an all-or-nothing phenomenon. It can –– Undescended testicle be complete (usually twisting > 360°), incomplete –– Testicular tumour 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

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HISTORY –– Trauma –– Sudden onset of severe, constant, unilateral pain –– Hernia in scrotum or testicle, usually for < 12–24 hours –– Hydrocele –– Prior episodes of intermittent testicular pain may –– Incarcerated or strangulated inguinal hernia be reported (torsion and then detorsion) –– Torsion appendix testis –– Pain may radiate to lower abdomen –– Acute varicocele –– May be described as abdominal or inguinal pain –– Testicular tumour by the embarrassed child –– Scrotal abscess –– Pain made worse by elevation of scrotum –– Testicular infarction –– Pain not relieved by lying down –– Henoch-Schönlein purpura –– Decreased appetite, nausea and vomiting may –– Appendicitis be present –– Urinary frequency may uncommonly occur COMPLICATIONS –– “Causes” as listed above –– Testicular atrophy For intermittent torsion: –– Infarction of testicle –– Infection –– Intermittent sharp testicular pain (resolves within –– Abnormal spermatogenesis seconds to minutes) –– Infertility –– Long periods without symptoms –– Number of occasions it occurred DIAGNOSTIC TESTS PHYSICAL FINDINGS –– Doppler ultrasonography helps distinguish testicular torsion from strangulated hernia, –– Temperature usually normal undescended testes or epididymitis –– Heart rate elevated –– If testicular torsion is present, a slight elevation of –– Blood pressure mildly elevated (because of pain) the testis increases pain whereas in epididymitis it –– Client in acute distress relieves pain –– Client bent over or unable to walk –– Unilateral scrotal swelling and redness MANAGEMENT –– Testis acutely tender, may be warm Goals of Treatment –– Testis swollen and found higher up (retracted) in the scrotal sac than expected on affected side –– Relieve pain –– Slight elevation of the testis increases or has no –– Prevent complications effect on pain Appropriate Consultation –– Testis might be lying horizontally (epididymis not posterolateral) If you suspect a testicular torsion, initiate a –– Hydrocele and scrotal skin erythema may be consultation with a physician without delay. This is present (often a later finding) a medical emergency; prompt diagnosis and surgical –– Cremasteric reflex (elevation of testis after stroking referral is critical to a satisfactory outcome. the upper, inner thigh on the same side) almost If intermittent torsion is suspected consult a physician. always not present Nonpharmacologic Interventions For intermittent torsion, in addition to the above, the following may also be present: –– Nothing by mouth before surgery –– Very mobile testes –– Bed rest –– Bulky spermatic cord –– Promote the patient’s comfort –– Normal examination Adjuvant Therapy DIFFERENTIAL DIAGNOSIS –– Start intravenous (IV) therapy with normal saline –– Epididymitis –– Adjust IV rate according to age and state of hydration –– Orchitis

2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 13–13

Pharmacologic Interventions Monitoring and Follow-Up Analgesia: If intermittent testicular torsion is suspected and the examination was normal, follow up in 7 days morphine 0.05–0.2 mg/kg/dose SC/IM/IV (maximum doses vary but generally should not (sooner if the pain recurs) and do another complete exceed morphine 5–10 mg) examination.

Usual maximum dose:31 Referral Infants: 2 mg/dose Medevac as soon as possible. This is a surgical Note: Infants < 3 months of age are more emergency. susceptible to respiratory depression; use with For those with suspected intermittent testicular caution and in reduced doses in this age group torsion, refer to a physician as a referral is Children 1–6 years: 4 mg/dose often warranted. Children 7–12 years: 8 mg/dose Adolescents: 15 mg/dose

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2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care