Pediatric Genitourinary Disorders

• This presentation covers genitourinary disorders in pediatrics focusing on circumcision, UTIs, enuresis, cryptorchidism, hypospadias/epispadias, phimosis, and paraphimosis.

Newborn Male GU Exam

• Examine the foreskin.
• Note the meatal position
• Check for hypospadias and epispadias by checking for abnormal meatus location.
• Look for chordee by checking for abnormal curvature.
• The average length of the penis is about 3.5 cm when stretched, with a normal range of 2.8 - 4.2 cm.
• Evaluate the scrotum for position and contents.
• Note the position of the penis in relation to the scrotum.
• Check for inguinal hernias.

Circumcision Decision

• AAP guidelines provide info, but the decision is up to the parents
• Circumcision dates back 6,000 years to Egypt.
• Circumcision is a common procedure performed on males in the U.S.
• Circumcision rates for males were 85% in 1965 and 58.3% in 2010.
• Circumcision rates globally are about 25%.
• Most countries link circumcision to religious tradition or local culture.
• Providers role is to equitably advocate for the infant and provide information.
• AAP has no official position for or against circumcision.

Circumcision: In Support

• Genital hygiene is easily maintained with soap and water.
• Studies show increased UTI risk with an intact prepuce.
• Circumcision reduces relative risk of UTI by 4-10x.
• Premature infants are less likely to be circumcised and have more urine cultures performed which can skew data.
• Colonization in uncircumcised males increases the risk of contamination.
• Overall reduced risk of certain non-HIV STIs with circumcision.
• The lifetime risk-reduction of HIV is 15.7%.
• Foreskin can be a risk factor for squamous cell carcinoma and phimosis is cited as the greatest risk factor.
• Reduced risk of penile cancer by 50% with an intact foreskin and no history of phimosis.

Circumcision: Opposing View

• Studies against circumcision benefits vary and don't always meet rigorous standards
• The true incidence of surgical complications is unknown.
• The acute complications include bleeding (0.08%-0.18%), infection (0.06%), and penile injury (0.04%).
• Late complications include adhesions (25.6%), redundant skin (20.1%), balanitis (15.5%), skin bridge (4.1%), and meatal stenosis (7%).
• Sexual effects are largely subjective, and studies do not support a loss or decrease in sensation with circumcision.
• Weighing risks and benefits is very challenging.
• The consensus in the U.S. is for parents to decide based on cultural, religious, and ethnic traditions.

Circumcision: Procedure

• Circumcision should be performed when the newborn is stable and healthy, ideally in the first week after birth.
• Circumcision is contraindicated in cases of hypospadias, congenital buried penis, neonatal illness, or bleeding disorders.
• Must be done with pain control using analgesics, sucrose nipple, topical anesthetic cream, dorsal penile nerve block, or sub-Q ring block.

UTI in Infants and Children

• Common pediatric complaint
• 0.7% of physician visits
• 5-14% ED visits
• Occurs in approximately 8% of girls and 2% of boys.
• Infants have the highest incidence of UTIs
• <6 months: Boys > girls, especially uncircumcised boys

• 6 months: Girls > boys

• 30% of infants experience another UTI after their initial presentation.

Common Bacteria

• E. coli
• Enterococcus faecalis
• Proteus mirabilis
• Klebsiella pneumoniae

UTI: Risk Factors

• Age < 12 months
• Circumcision status, specifically in infants
• Bowel and bladder dysfunction (BBD)
• Congenital kidney and urogenital tract anomalies
• Spinal dysraphism/spina bifida
• Constipation and encopresis
• Poor hygiene
• Urinary obstruction
• Neurogenic bladder
• Vesicoureteral reflux (VUR)
• Systemic diseases like diabetes mellitus, HIV, immunocompromised state, sickle cell disease
• Sexual activity
• Kidney stones
• Urinary tract instrumentation/catheterization

UTI: Pt Presentation

• Fever
• Vomiting
• Hypothermia
• Irritability
• Diarrhea
• Jaundice
• Poor feeding
• Failure to thrive
• Possibly nonspecific results on PE
• Fever
• Abdominal pain
• Urgency
• Frequency
• Hematuria
• Dysuria
• Lower back pain
• Possible suprapubic tenderness on PE
• Pyelonephritis may present with fever, vomiting, and CVA tenderness.

Urine Collection Methods

• Perineal collection bags are convenient, but have a false-positive rate as high as 85%.
• Catheterization is a collection method used in infants and diapered children.
• Suprapubic aspiration is used in infants and diapered children when sepsis is suspected and is contraindicated with abdominal distention or empty bladder
• Clean-catch is used in toilet-trained children and adolescents.

Positive Urinalysis

• The diagnosis of UTI is confirmed by growth of a single pathogen on culture and significant pyuria on urinalysis.
• Significant pyuria is > 5 WBCs/hpf.
• Leukocyte esterase presence correlates well with pyuria.
• Nitrite presence correlates well with UTI.
• Any growth on suprapubic collection.
• Catheterization is confirmed with >10,000-100,000 CFU/mL
• Clean catch is confirmed with >100,000 CFU/mL

UTI Treatment

• Children < 3 months with a UTI should have a urine sample sent for urgent microscopy and culture, and treatment should be initiated
• Children 3 months to 3 years with specific urinary symptoms need antibiotic treatment, and urine sample for urgent microscopy and culture initiated. If nonspecific urinary symptoms, assess risk.
• Children > 3 years of age, perform urine dipstick test
• Uncomplicated cystitis is treated with Cephalosporins(1st/3rd gen), Trimethoprim-sulfamethoxazole, or Amoxicillin.
• Teens can be treated with Fluoroquinolones for 3 days
• Pyelonephritis is treated with IV antibiotics followed by PO antibiotics, 3rd gen Cephalosporin, or Aminoglycosides and treatment is 10 - 14 days.
• If the patient needs to be admitted they should be under 3 months old, clinical urosepsis, dehydration etc.

Prophylactic Antibiotics

• May be administered in children with recurrent UTIs
• May be administered in children exhibiting high-grade vesicoureteral reflux (VUR)
• May be administered in children exhibiting dysfunctional voiding
• Options include Trimethoprim-sulfamethoxazole
• Options include Nitrofurantoin

Enuresis

• Intermittent urinary wetting while asleep (bedwetting)
• Nocturnal is often added for clarification
• Daytime + nighttime wetting = daytime incontinence and enuresis
• Monosymptomatic - no other lower urinary symptoms
• Complicated/Polysymptomatic - associated with change in frequency, daytime incontinence, dribbling, urgency, hesitancy, withholding, straining, and pain
• 2x/week indicates Primary which is never dry, and must be >3mo
• 2x/week indicates Secondary which is dry >6mo and must be >5yrs

Enuresis: Associated Medical Conditions

• Hereditary
• Constipation
• OSA
• Anatomical abnormalities of the GU, renal or spine
• Endocrine disorders
• Medications
• Withholding
• Overactive Bladder
• Stress Incontinence
• UTI

Enuresis: Diagnosis/Treatment/Prognosis

• Diagnosis - UA/Cx, US renal and bladder, voiding cystogram, MRI of the spine
• Treatment - Underlying conditions, lifestyle changes, alarms, medications
• Prognosis - Will take a long time

Enuresis Medication

• Desmopressin (DDAVP) - dose 0.2-0.6mg PO qhs and given 2-3 months for control
• Oxybutynin - 5mg PO qhs, add-on med that is off-label
• Imipramine - 10-25mg PO qhs, add-on med

Cryptorchidism

• Cryptorchidism (undescended or absent testes) effects >30% premature infants.
• Other risk factors - SGA or BW less than 2500g, breech, maternal DM, twin birth, brother with crypt, and assoc with syndromes
• Descent usually occurs around 36 weeks.
• Spontaneous descent after 6 months is rare
• May present with inguinal hernia, hydrocele, or testicular torsion.
• Most common: palpable and on the right side.
• Diagnosis: If non-palpable, start with US, consider MRI, exploratory surgery (the gold standard)
• Virilized female with Congenital Adrenal Hyperplasia (CAH)
• Retractile testes
• Treatment: Observe for 6 months and then proceed with Orchidopexy: by 1 year old and with controversy: hCG
• Outpatient surgery utilizing general anesthesia
• Post-Op: Pain control medications as needed, minimal pain medication is required is needed in the first 24 to 48 hours, incision site should be kept dry 48 hours, PE and playing on straddle toys should be avoided, long-term follow ups and testicular exams are important, and there is a chance of recurrence
• Complications of untreated Cryptorchidism include infertility and testicular malignancy

Hypospadias

• Abnormal formation of ventral structures of the penis and urethra
• Ventral meatus placement
• Endocrine disruptors seem to increase risk
• Most cases are glanular to subcoronal (anterior/distal)
• Increased incidence of intersexuality with cryptorchidism and posterior/proximal hypospadias
• Both testicles normally descended if isolated malformation
• Diagnosis - Made clinically, but more severe cases may require a cystourethrogram
• Mild - Observe
• Surgical repair - between 6 to 12 months with circumcision AVOIDED to retain tissue
• Goal of surgery is cosmetic, to allow the patient to urinate while standing, allow of erections without pain, and psychological benefits
• Post-Opt: Catheterization for 1-3 weeks, sometimes urethral stents are placed, hormonal therapy is sometimes used AND controversial
• Complications: FIstulas, meatal stenosis, urethral diverticulum/stricture. Erectile dysfunction in adulthood
• Other Referrals: Pediatric endocrinologist to geneticist

Epispadias

• Rare congenital defect of the urethra
• Male at birth will open on the dorsal side; rarely will it open above the clitoris
• Symptoms include difficulty urinating, incontinence, frequent and painful urination, UTIs and sexual dysfunction

Phimosis

• The inability to retract the foreskin over the glans penis
• Physiologic phimosis occurs naturally in newborns and is loose unscarred and resolves spontaneously
• Pathologic phimosis - Inability to retract forsaking after previously retractable or after puberty (often secondary to scarring of foreskin tightness)
• Causes for Pathologic Phimosis: Infections/inflammation/scarring, premature retraction, chronic dermatitis and stem-cell-transplant/gvhd
• Pathologic Phimosis can be treated with medium potency steroid cream- Gently retract with referral to urology
• In some cases surgery may be needed

Paraphimosis

• Retracted forsaking inability to return to normal position In uncircumcised males.
• Often iatrogenic AND an emergency
• Attempt manual reduction if early stages and use ice pack/topical lidocaine with anesthesia as condition/progression increase with surgery needed if no reduction, necrosis, or urinary retention requiring a dorsal-split

Paraphimosis- Post Opt

• Apply petroleum jelly and a sterile gauze, prescribe oral opiods
• Wear loose-fitting clothes and wash the wound daily with DO NOT retract foreskin
• No sexual activity and the follow up with PCP in 1-2 weeks