Pediatric Clinical Practice Guidelines for Nurses in Primary Care
Chapter 13 - Genitourinary system
Assessment of the Genitourinary System
Common Problems of the Genitourinary System
Emergency Problems of the Male Genital System
For more information on the history and physical examination of the genitourinary
system in older children and adolescents, see chapter
6, "Urinary and Male Genital Systems," and chapter
13, "Women's Health and Gynecology," in the adult clinical guidelines
(First Nations and Inuit Health Branch 2000).
For balanitis and testicular torsion (a medical emergency), clinical presentation
and management are the same in adults and children. For information on these
conditions, see chapter
6, "Urinary and Male Genital Systems," in the adult clinical
guidelines (First Nations and Inuit Health Branch 2000).
Assessment of the Genitourinary System
General
he genitourinary (GU) system may be affected by infection, external problems,
congenital abnormalities and diseases of the kidneys. Some of the more common
problems are discussed below.
History of Present Illness and Review of System
The following symptoms are those most commonly associated with urinary tract
infection (UTI) in children:
- Fever - Unexplained crying
- Holding of genitals
- Enuresis (bed-wetting)
- Constipation (chronic)
- Toilet-training problems
- Dysuria
- Frequency
- Urgency
- Change in color of urine
- Abdominal pain and back pain
- Scrotal or groin pain, vaginal discharge
- Genital sores, swelling, discoloration
The following symptoms are associated with nephrotic syndrome and glomerulonephritis:
- Swelling (e.g., ankles, around eyes)
- Headaches
- Nosebleeds (an occasional symptom of hypertension, but nosebleeds also
occur frequently in normal children)
- Hematuria
- Decreased urinary output
A complete history of the GU system should include questions
related to the following topics:
- Sexual activity (for adolescents)
- Problems related to inappropriate touching by others (i.e., 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
- Blood pressure
Urinary System (Abdominal Examination)
For full details, see "Examination
of the Abdomen," in chapter 12, "Gastrointestinal System."
Inspection
- Check specifically for any abdominal distension (a sign of ascites)
- Masses
- Asymmetry
Percussion
- 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
- 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
- Position of urethra (e.g., epispadias, hypospadias)
- Discharge at urethra (sign of urethritis)
- Inflammation of foreskin or head of penis (sign of balanitis)
Palpation
- Foreskin adherent at birth
- In 90% of uncircumcised male children, the foreskin becomes partially or
fully retractable by 3 years of age
- Inability to retract foreskin (phimosis)
- Inability of retracted foreskin to return to normal position (paraphimosis)
Scrotum and Testicles
Inspection
- Scrotum may appear enlarged
- Check for edema (a sign of glomerulonephritis), hydrocele (transillumination
should be possible), hernia or varicocele
Palpation
- Cremasteric reflex (absent in testicular torsion)
- Testicular size, 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
For information about examining the adolescent male,
see "Physical
Examination of the System," in chapter 6, "Urinary and Male Genital
Systems," in the adult clinical guidelines (First Nations and Inuit
Health Branch 2000).
Female Genitalia
- 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 introitus
Inspection
- Vulvar irritation
- Erythema (in prepubescent girls, the labia normally appears redder than
in adult women, because the tissue is thinner)
- Urethral irritation (sign of UTI)
- Vaginal discharge (may indicate vaginitis or sexual abuse)
- Bleeding (may indicate vaginitis or sexual abuse in a prepubescent girl)
- Enlargement of vaginal orifice (may indicate sexual abuse)
For information about examining the adolescent female,
see "Examination
of the Female Reproductive System," in chapter 13, "Women's Health
and Gynecology," in the adult clinical guidelines (First Nations
and Inuit Health Branch 2000).
Common Problems of the Genitourinary System
Urinary Tract Infection (UTI)
Definition
Bacterial invasion of the GU tract with resulting infection.
- Cystitis: infection affecting only the lower GU tract (e.g., the
bladder)
- Pyelonephritis: ascending infection involving the upper GU tract(e.g.,
the ureters and kidneys)
UTI is the most common genitourinary disease in children. It occurs more frequently
in girls than in boys, except in infancy. In fact, UTI is unusual in boys,
and further investigation of the GU tract is appropriate when it occurs.
Causes
Bacterial invasion by one of the following organisms:
- Escherichia coli
- Klebsiella
- Enteric Streptococcus
- Staphylococcus
- Proteus
- Predisposing factors: congenital GU tract abnormalities (e.g., short urethra),
although most children with UTI have normal GU tract; perineal fecal contamination
because of inadequate hygiene; infrequent voiding; perianal infections; sexual
activity
History
The history depends on the child's age.
Neonates and Infants
- Primarily non-specific, non-urinary symptoms
- May present with septicemia
- Fever
- Irritability ("colic")
- Poor feeding
- Vomiting, diarrhea
- Jaundice (particularly in neonates)
- Hypothermia
- Failure to thrive
- Decreased activity, lethargy
Younger Children (≤3 Years Old)
- More abdominal complaints than GU complaints
- Fever
- Abdominal pain
- Vomiting
- Frequency, urgency, dysuria, enuresis, strong-smelling urine
- Urinary retention
Older Children (>3 Years)
- Frequency
- Dysuria
- Urgency
- Enuresis
- Flank or back pain (this probably indicates pyelonephritis, not cystitis)
- Fever
- Vomiting
Physical Findings
- Fever (may be absent in simple cystitis)
- Suprapubic tenderness (in cystitis)
- Tenderness of abdomen, flank and costovertebral angle (more likely with
pyelonephritis)
Be sure to assess hydration status.
Differential Diagnosis
Distinguish between cystitis and pyelonephritis.
Infection of the Lower GU Tract
- Urethral irritation (e.g., bubble bath)
- Urethral trauma
- Diabetes mellitus
- Masses adjacent to bladder
Infection of the Upper GU Tract
- Gastroenteritis
- Pelvic inflammatory disease (PID)
- 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 microscopy (midstream specimen for children, catheter
specimen for infants):
- WBCs
- Bacteriuria
- Some hematuria (blood in urine)
- Positive for nitrates (although UTI can occur with organisms that do not
produce nitrate)
Urine for culture and sensitivity:
- Preferable to use first morning specimen
- If multiple organisms present on culture, suspect contamination, not true
infection
Management
Lower GU infections (e.g., cystitis) are generally less
severe and can be managed safely on an outpatient basis. Pyelonephritis is
more severe and may require hospital care for IV antibiotics. The decision
about hospitalization depends on the child's age and the severity of the clinical
condition.
Goals of Treatment
- Relieve infection
- Prevent recurrence
- Identify underlying factors
Appropriate Consultation
Consult a physician for any of the following:
- Neonatal infections, for which medevac is required; these are often associated
with bacterial sepsis, so more aggressive treatment is needed
- Suspected pyelonephritis, for which child may be admitted to hospital (depends
on age and severity of illness)
Cystitis
Nonpharmacologic Interventions
- Increased rest if febrile
- Increased oral fluids
Pharmacologic Interventions
Do not treat as UTI unless results of urine dipstick are
indicative of such a diagnosis (e.g., positive for nitrates or WBCs).
Antibiotics:
amoxicillin (Amoxil) (A class drug), 100 mg/kg per day, divided
tid, PO for 10 days
or
sulfamethoxazole - trimethoprim (Septra) (A class drug), 5-10
mg/kg per day, divided bid, PO for 7-10 days
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 (Ampicin)(D class drug), 200 mg/kg per day, divided
q6h, IV
and
gentamicin (Garamycin) (B class drug), 2.5 mg/kg per dose
tid
Monitoring and Follow-Up
- If treating as an outpatient, follow up in 24-48 hours. Check sensitivity
of organisms to antibiotics when urine cultures are available.
- If no response to oral antibiotics after 48-72 hours or if symptoms are
deteriorating, consult with a physician about changing the antibiotic or
the need for IV antibiotic therapy
- Perform follow-up urinalysis and culture 1 week after completion of treatment
and then monthly for 3 months (if anatomy of the GU tract is normal)
Referral
- Medevac all neonates
- Older infants and children with suspected pyelonephritis may require medevac,
depending on their age and clinical condition
- Refer to a physician (for evaluation) any child with culture-proven UTI
who has been treated on an outpatient basis
Radiologic evaluation may be indicated in any girl who
has had more than two or three culture-proven lower UTIs, in any boy who has
had one culture-proven lower UTI and in any child who has had pyelonephritis;
such evaluation includes renal ultrasonography and voiding cystourethrography
(VCUG).
Hydrocele (Physiologic)
Definition
In infant boys, a mild scrotal swelling, resulting from a collection of fluid
around the testicle (unilateral or bilateral). It may be confused with a groin
node. Usually present from birth and usually due to patency of the processus
vaginalis.
Occurs only rarely in infant girls, in whom it presents as a firm swelling
in the groin.
Cause
History
- Painless swelling in scrotum, of variable size
- Congenital or acquired
- Most cases resolve by age 1 year
- Swelling may fluctuate in size
Physical Findings
- Should be able to palpate an upper border of the swelling
- Testis is usually felt behind the mass, but may be difficult to feel
- Transillumination of the swelling should be possible
- Inguinal hernia may also be present
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
- Inguinal hernia
- Trauma
- Cystic lesion
- Hematoma
- Neoplasm
Complications
- Slight increase in risk of inguinal hernia
Diagnostic Tests
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 (e.g., infection)
- There is an associated inguinal hernia
Nonpharmacologic Interventions
- 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
(e.g., 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
- Hernias are associated with the hydrocele
Prepubescent Vaginal Discharge
For vaginal discharge in adolescents, see "Vulvovaginitis," in
chapter 13, "Women's Health and Gynecology," in the adult
clinical guidelines (First Nations and Inuit Health Branch 2000).
Definition
Physiologic discharge:
- Mucoid
- Non-malodorous
- Seen in newborns and premenarchal girls (Tanner stage II and III); (for
definition of Tanner stages, see "Puberty,"in
chapter 19,"Adolescent Medicine")
- 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)
- Autoinoculation from associated URTI (Hemophilus influenzae, group
B Streptococcus) or skin infections (Staphylococcus)
- Pinworms (E. coli)
- Foreign body (associated with E. coli)
- 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 (i.e., <14
years), sexual abuse must be considered.
History
- Various degrees of perineal discomfort or itching
- Dysuria
- Frequency
- Associated illnesses (e.g., URTI, skin problems, pinworms)
- Hygiene
- Possible sexual abuse
Physical Findings
Do not perform a vaginal speculum examination.
- Suboptimal general or perineal hygiene
- Signs of URTI or skin disease
Labial Irritation
- Consider problems with perineal hygiene
- Candida
- Sexual abuse
Marked Erythema
Vaginal Discharge
- May be fairly non-specific
- Thick, white, cheesy: Candida
- Frothy, green: Trichomonas
Foreign Body
- May be visualized better if child is in knee-chest position
- May be able to palpate a foreign body while doing a rectal examination
Differential Diagnosis
Non-infectious
- Poor hygiene
- Chemical irritation (e.g., from bubble bath)
- Foreign body
- Trauma
Infectious
- Group A Streptococcus infection
- Non-specific bacterial infection
- Pinworms
- Candida (less common)
- STD (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)
Diagnostic Tests
If child is cooperative, attempt to swab vaginal orifice (using small Calgi
I swab); avoid touching the hymenal edge. Swab for Chlamydia, N.
gonorrhoeae, culture and sensitivity, and hanging drop, in that order.
Management
Management depends on cause.
Goals of Treatment
- Identify and correct underlying cause
Appropriate Consultation
Consult a physician if child is febrile or has abdominal pain, or if you suspect
sexual abuse.
If the child is <14 years old and there was sexual
activity involving an adult partner, the legal definition of sexual abuse specifies
that legal (e.g., police) and child protection authorities must be notified.
Nonpharmacologic and Pharmacologic Interventions
For Poor Hygiene
- Improve perineal hygiene (e.g., use of clean cotton panties, frequent changing
of underwear)
- 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 possible;
otherwise consult a physician about removal.
Give:
amoxicillin (Amoxil) (A class drug), 40 mg/kg
per 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
- nystatin cream (Mycostatin) (A class drug), PV od for
6 days
For Trichomonal Infection
- metronidazole (Flagyl) (A class drug), 1-2 g PO stat
For Bacterial Vaginosis
- metronidazole (Flagyl) (A class drug), 1-2 g PO stat
For Sexually Transmitted Disease
Consult a physician if you suspect an STD in a preadolescent
child. Refer to and follow the Canadian STD Guidelines (Health Canada
1998).
If the cause of the discharge is uncertain, send samples
for culture (according to child's age), as above, and treat with amoxicillin
(Amoxil) pending results of culture.
Report as suspected sexual abuse all cases of gonorrhea
and Chlamydia infection in girls <14 years old who have been sexually
active with an adult (in accordance with the legal definition of sexual abuse).
Other cases of vaginitis may be reportable, depending on the circumstance.
Glomerulonephritis
Definition
Disease in which there is immunologic or toxic damage to the glomerular apparatus
of the kidneys. It can occur acutely, or it may have a chronic or insidious
onset.
Some types of glomerulonephritis are self-limiting, and others may go on to
cause permanent kidney damage.
The most common type in northern Canada is post-streptococcal glomerulonephritis,
described below. Any suspected glomerulonephritis should be fully investigated.
Causes
- Usually secondary to previous streptococcal infection (e.g., of the throat
or skin)
- Follows pharyngitis by 1-3 weeks
- Lag time after skin infections is variable, but most frequently 1-2 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
- Abdominal pain
- Fever
- Headaches
- 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 75% of cases)
- Hypertension (in about 50% of cases)
- Hematuria (two-thirds of children have gross hematuria)
- Proteinuria
- Oliguria
- Renal failure (to variable degree)
- Congestive heart failure
- 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
Complications
- Acute renal failure
- Congestive heart failure
- Hyperkalemia
- 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)
Pharmacologic Interventions
None, unless complications develop. Treat complications only on
physician's instruction.
Monitoring and Follow-Up while Awaiting Transfer
- Fluid restriction (to 60 ml/kg per day + urine losses)
- Monitor blood pressure and vital signs
- 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.
Balanitis
See "Balanitis," in
chapter 6, "Urinary and Male Genital Systems," in the adult
clinical guidelines (First Nations and Inuit Health Branch 2000).
Emergency Problems of the Male Genital System
Testicular Torsion
See "Testicular
Torsion," in chapter 6, "Urinary and Male Genital Systems,"in
the adult clinical guidelines (First Nations and Inuit Health Branch 2000).
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