Pediatric Primary Care (91 page)

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.

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.

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

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

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

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.