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 Review of Systems ...........................................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 Urinary Incontinence (Enuresis) .......................................................................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 diseases 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 urination – Smoky or coffee-coloured urine – Screaming on urination – Decreased urinary output – Poor urine stream – Pallor – Foul-smelling urine – Weight gain – Enlarged kidney 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 signs and symptoms 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 – Dysuria – Heart rate – Hematuria – Respiratory rate – Frequency – Blood pressure – Urgency Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010 13–2 Genitourinary System URINARY SYSTEM (ABDOMINAL – Discharge at urethra (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 Scrotum and Testicles – Determine organ size Inspection: – Liver span (may be increased in glomerulonephritis) – Scrotum may appear enlarged – Ascites (dull to percussion in flanks when child – Check penile and scrotal skin 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, varicocele 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 testicle) (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 anatomy 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, epispadias, hypospadias) 2010 Pediatric Clinical Practice Guidelines for Nurses in Primary Care Genitourinary System 13–3 – 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 Disease 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 – Abdominal pain 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 – Joint 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) – Oliguria 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