Pediatric Primary Care (90 page)

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.

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

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.

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.

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

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.