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Dysuria in Children

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381. Septic Shock (Overview)

. (See , , , and .) This article does not cover sepsis of the neonate or infant. Special consideration must be given to neonates, infants, and small children with regard to fluid resuscitation, appropriate antibiotic coverage, intravenous (IV) access, and vasopressor therapy. (See , , , , and .) Shock Classification, Terminology, and Staging Shock is identified in most patients by hypotension and inadequate organ perfusion, which may be caused by either low cardiac output or low systemic vascular (...) and gastrointestinal (GI) infections – Diarrhea, abdominal pain, abdominal distention, guarding or rebound tenderness, rectal tenderness or swelling Pelvic and genitourinary (GU) infections – Pelvic or flank pain, adnexal tenderness or masses, vaginal or urethral discharge, dysuria, frequency, urgency Bone and soft-tissue infections – Localized limb pain or tenderness, focal erythema, edema, swollen joint, crepitus in necrotizing infections, joint effusions Skin infections – Petechiae, purpura, erythema

2014 eMedicine.com

382. Urinary Tract Obstruction (Overview)

obstruction is usually indolent and may be asymptomatic. When infection is present, the patient may experience fever, chills, and dysuria. Hematuria may also be present. When bilateral obstruction or unilateral obstruction in a solitary kidney is severe and renal failure has occurred, uremia can be present. Uremia symptoms include weakness, peripheral edema, mental status changes, and pallor. If hydronephrosis is severe, the kidney may be palpable on physical examination, especially in children. In cases (...) . In men, hydronephrosis is most likely after age 60 years secondary to prostatic obstruction. Hydronephrosis is found in 2-2.5% of children. Previous Next: Etiology Obstruction of urinary flow can occur anywhere from the kidneys to the urethral meatus. Dividing the urinary tract into the upper urinary tract, defined as the kidney and ureter to the hiatus with the bladder, and the lower urinary tract, defined as the bladder and urethra to the urethral meatus, allows for further delineation of the cause

2014 eMedicine.com

383. Urinary Tract Infections in Pregnancy (Overview)

mucosal vaccine for urinary tract infections. J Urol . 2003 Sep. 170(3):867-9. . Mann JR, McDermott S. Are Maternal Genitourinary Infection and Pre-Eclampsia Associated With ADHD in School Aged Children?. J Atten Disord . 2010 Sep 13. . Sun Y, Vestergaard M, Christensen J, Nahmias AJ, Olsen J. Prenatal exposure to maternal infections and epilepsy in childhood: a population-based cohort study. Pediatrics . 2008 May. 121(5):e1100-7. . Kazemier BM, Koningstein FN, Schneeberger C, Ott A, Bossuyt PM, de (...) and childhood neurologic consequences. For patient education information, see the and , as well as , , , and . Definitions of key terms Urinary tract infection UTI is defined as the presence of at least 100,000 organisms per milliliter of urine in an asymptomatic patient, or as more than 100 organisms/mL of urine with accompanying pyuria (> 7 white blood cells [WBCs]/mL) in a symptomatic patient. A diagnosis of UTI should be supported by a positive culture for a uropathogen, particularly in patients

2014 eMedicine.com

384. Urinary Tract Infection, Females (Overview)

of estrogen with attendant changes in vaginal flora (notably, loss of lactobacilli), which allows periurethral colonization with gram-negative aerobes, such as E coli; and higher likelihood of concomitant medical illness, such as diabetes. Of neonates, boys are slightly more likely than girls to present with UTI as part of a gram-negative sepsis syndrome. The incidence in preschool-aged children is approximately 2% and is 10 times more common in girls. UTI occurs in 5% of school-aged girls, but it is rare (...) infection) represents the majority of these infections (see the image below). Related terms include pyelonephritis, which refers to upper urinary tract infection; bacteriuria, which describes bacteria in the urine; and candiduria, which describes yeast in the urine. Plain radiograph in a 63-year-old patient with poorly controlled type 2 diabetes mellitus shows emphysematous cystitis. Signs and symptoms Symptoms and signs of UTI in the adult are as follows: Dysuria Urinary urgency and frequency

2014 eMedicine.com

385. Urethritis (Overview)

, including approximately 25% of those with NGU, are asymptomatic and present to a clinician following partner screening. [ ] Up to 75% of women with Chlamydia trachomatis infection are asymptomatic. Signs and symptoms in patients with urethritis may include the following: Urethral discharge: May be yellow, green, brown, or tinged with blood; production unrelated to sexual activity Dysuria (in men): Usually localized to the meatus or distal penis, worst during the first morning void, and made worse (...) is highest in the summer months. International Worldwide, approximately 62 million new cases of gonococcal urethritis and 89 million new cases of NGU are reported each year. Previous Next: Mortality/Morbidity Approximately 10%-40% of women with urethritis eventually develop (PID), which may subsequently cause and ectopic pregnancy secondary to postinflammatory scar formation in the fallopian tubes. PID can occur even in women with asymptomatic infections. Children born to mothers with Chlamydia infection

2014 eMedicine.com

386. Urinary Tract Infection, Males (Overview)

to the normal male urinary tract’s many natural defenses to infection, many experts consider UTIs in males, by definition, to be complicated (ie, more likely to be associated with anatomic abnormalities, requiring surgical intervention to prevent sequelae). Signs and symptoms Dysuria is the most frequent chief complaint in men with UTI. The combination of dysuria, urinary frequency, and urinary urgency is about 75% predictive for UTI, whereas the acute onset of hesitancy, urinary dribbling, and slow stream (...) organisms can retard ureteral peristalsis. E coli is responsible for approximately 25% of cases in males, with and causing many remaining infections; , Pseudomonas , , and are less frequent. Bacterial cystitis Bacterial cystitis without concomitant infection in other portions of the genitourinary tract is believed to be a rare event in males. The abrupt onset of irritative voiding symptoms (eg, frequency, urgency, nocturia, dysuria) and suprapubic pain are clinically diagnostic. Most cases of bacterial

2014 eMedicine.com

387. Uric Acid Nephropathy (Overview)

practice, the prognosis for persons with acute renal failure from acute urate nephropathy is excellent. The morbidity of uric acid nephrolithiasis arises from the manifestations of stones, obstruction, and crystalluria and is often accompanied by dysuria and hematuria. [ ] Secondary bacteriuria and pyelonephritis also can occur. However, life-threatening complications are rare. Race See the list below: A number of different malignancies cause a predisposition to acute uric acid nephropathy, making (...) demographics for this entity difficult to characterize. Sex See the list below: Uric acid nephrolithiasis occurs most frequently in those with underlying hyperuricemia or gout, which occurs in men more frequently than women by a male-to-female ratio of 4:1. In the United States, the prevalence rate is 4-9% in men and 1.7-4.1% in women. Age See the list below: Uric acid nephropathy has been well documented in the pediatric and adult populations. It may occur more often in pediatric patients because

2014 eMedicine.com

388. Urethral Syndrome (Overview)

Updated: Jun 23, 2017 Author: Martha K Terris, MD, FACS; Chief Editor: Edward David Kim, MD, FACS Share Email Print Feedback Close Sections Sections Urethral Syndrome Overview Practice Essentials Urethral syndrome is characterized by urinary frequency, dysuria, and suprapubic discomfort without any objective finding of urological abnormalities. It is also characterized by sterile urine culture results and urinary frequency that is typically worse during the day than during the night. The dysuria (...) syndrome is to relieve the discomfort and urinary frequency. This often involves a trial-and-error approach that uses behavioral, dietary, and medical therapy. See and . Next: Background Urethral syndrome was originally described as urinary frequency and dysuria without demonstrable infection. As a diagnosis, urethral syndrome (also known as frequency-dysuria syndrome) is controversial, and the term (coined by Powell and Powell in 1949) may be outdated, partially because of the lack of consensus

2014 eMedicine.com

389. Urethral Prolapse (Overview)

is predominantly asymptomatic. Often, urethral prolapse is an incidental finding during routine examination. The most common presentation is vaginal bleeding associated with a periurethral mass. [ ] Symptomatic children present with bloody spotting on their underwear or diapers. is uncommon. Until urethral prolapse is definitively diagnosed, the presence of blood in the genital area should raise suspicion of and warrant ruling out this possibility. Voiding disturbances are typically rare in the pediatric (...) population, but when they are present, patients may report dysuria, urinary frequency, or introital pain. Again, hematuria is uncommon. Children may report genital pain if the prolapsed mucosa becomes very large or if thrombosis and necrosis have developed. Furthermore, although reportedly a nonobstructive lesion, acute urinary retention secondary to urethral prolapse has been reported. [ ] In contrast, patients with postmenopausal urethral prolapse are often symptomatic. Vaginal bleeding associated

2014 eMedicine.com

390. Urethral Diverticula (Overview)

been identified with increasing frequency over the past several decades because of increased physician awareness of the condition. The most common symptoms associated with urethral diverticula include urinary frequency, urgency, and dysuria. In some cases, and calculi are also present. Despite the increased awareness in recent years, this entity continues to be overlooked during routine evaluation of women with voiding problems. Accurate diagnosis and treatment of urethral diverticula require (...) . Congenital urethral diverticula are rare; however, urethral diverticula in children have been used to support the congenital origin theory. Congenital urethral diverticula have been postulated to arise from the following: Remnant of Gartner duct Faulty union of primordial folds Cell rests Vaginal wall cysts of müllerian origin Congenital dilatation of periurethral cysts Association with blind-ending ureters Acquired diverticula may originate from repeated urinary tract infections obstructing

2014 eMedicine.com

391. Urethral Caruncle (Overview)

. Cases of urethral melanoma, [ ] , [ , ] intestinal ectopia, lymphoma, [ , ] and urethral leiomyoma [ ] masquerading as urethral caruncle have been reported; however, reports of these associations are rare. Intraepithelial squamous cell carcinoma arising within a urethral caruncle has been reported in two patients. [ ] Additionally, urethral caruncles have been reported to occur rarely in the premenopausal patient and may enlarge during pregnancy. Urethral polyps are the pediatric equivalent (...) of urethral caruncles and manifest in a similar fashion. Previous Next: Presentation Most urethral caruncles are asymptomatic and are incidentally noted on pelvic examination; however, some may be painful and others may be associated with dysuria. Many individuals with a urethral caruncle present with bleeding or, more commonly, with the patient noticing blood on undergarments. Urethral caruncles are unlikely to explain voiding or storage symptoms in women. In fact, a comparison of lower urinary tract

2014 eMedicine.com

392. Surgical Treatment of Vaginal Cancer (Overview)

botryoides (embryonal rhabdomyosarcoma) Rare 3y Local, blood, lymphatic Most common vaginal cancer among children, grapelike mass, strap cells Endodermal sinus tumor (yolk sac tumor) Very rare 10mo Local Aggressive, alpha-fetoprotein (AFP) as marker Leiomyosarcoma < 2% Wide range Local, blood, lymphatic Grade is most important prognostic factor, can be secondary to pelvic irradiation HPV and other infectious agents The identification of HPV deoxyribonucleic acid (DNA) in squamous cell cancer cells (...) report urinary symptoms, which are caused by an anterior lesion compressing or invading the bladder, the urethra, or both. This causes bladder pain, dysuria, urgency, and hematuria. About 15-30% of patients present with pelvic pain. Posterior lesions compress or invade the rectosigmoid, which causes tenesmus or constipation. Only 10% of patients report a vaginal mass or vaginal prolapse. In 2000, Eltabbakh and coworkers reported a single patient who presented with a cystic pelvic mass arising from

2014 eMedicine.com

393. Reactive Arthritis (Follow-up)

of Poncet's disease. From the description of 198 cases found in the literature. Clin Rheumatol . 2013 Jul. 32(7):929-35. . Prati C, Bertolini E, Toussirot E, Wendling D. Reactive arthritis due to Clostridium difficile. Joint Bone Spine . 2010 Mar. 77(2):190-2. . Durand CL, Miller PF. Severe Clostridium difficile colitis and reactive arthritis in a ten-year-old child. Pediatr Infect Dis J . 2009 Aug. 28(8):750-1. . Macía Villa C, Sifuentes Giraldo W, Boteanu A, González Lanza M, Bachiller Corral J (...) (2):121-3. . Simonini G, Taddio A, Cimaz R. No evidence yet to change American Heart Association recommendations for poststreptococcal reactive arthritis: comment on the article by van Bemmel et al. Arthritis Rheum . 2009 Nov. 60(11):3516-8; author reply 3518-9. . Moorthy LN, Gaur S, Peterson MG, Landa YF, Tandon M, Lehman TJ. Poststreptococcal reactive arthritis in children: a retrospective study. Clin Pediatr (Phila) . 2009 Mar. 48(2):174-82. . Siala M, Gdoura R, Younes M, Fourati H, Cheour I

2014 eMedicine.com

394. Reactive Arthritis (Follow-up)

of Poncet's disease. From the description of 198 cases found in the literature. Clin Rheumatol . 2013 Jul. 32(7):929-35. . Prati C, Bertolini E, Toussirot E, Wendling D. Reactive arthritis due to Clostridium difficile. Joint Bone Spine . 2010 Mar. 77(2):190-2. . Durand CL, Miller PF. Severe Clostridium difficile colitis and reactive arthritis in a ten-year-old child. Pediatr Infect Dis J . 2009 Aug. 28(8):750-1. . Macía Villa C, Sifuentes Giraldo W, Boteanu A, González Lanza M, Bachiller Corral J (...) (2):121-3. . Simonini G, Taddio A, Cimaz R. No evidence yet to change American Heart Association recommendations for poststreptococcal reactive arthritis: comment on the article by van Bemmel et al. Arthritis Rheum . 2009 Nov. 60(11):3516-8; author reply 3518-9. . Moorthy LN, Gaur S, Peterson MG, Landa YF, Tandon M, Lehman TJ. Poststreptococcal reactive arthritis in children: a retrospective study. Clin Pediatr (Phila) . 2009 Mar. 48(2):174-82. . Siala M, Gdoura R, Younes M, Fourati H, Cheour I

2014 eMedicine.com

395. Pyelonephritis, Acute (Follow-up)

associated obstruction. The groups at greatest risk are infants and preschool-aged children. Initial management varies with patient age and presentation. Close follow-up examination, regardless of whether the patient is initially admitted, is essential to ensure recovery. Immediate reevaluation is encouraged for any recurrence of symptoms, because neither treatment of asymptomatic bacteriuria nor long-term suppressive therapy has been found to be effective. Urologic evaluation is necessary to establish (...) the presence of any urologic abnormality. The preferred imaging study for the diagnosis of acute pyelonephritis is technetium-99m dimercaptosuccinic acid ( 99m Tc-DMSA) scintigraphy. Ultrasonography is the imaging study of choice for the diagnosis of urinary tract structural abnormalities. Age-related data adapted from Harwood-Nuss and colleagues and Hansson and colleagues are presented below in Table 5. [ , ] Table 5. Pediatric Urinary Tract Infections Neonates Infants 6 weeks to 3 years of age Children 3

2014 eMedicine.com

396. Bladder Cancer (Overview)

, and vagina with squamous cell carcinoma of the bladder infiltrating through the bladder wall into the vaginal wall. Signs and symptoms Clinical manifestations of bladder cancer are as follows: Painless gross hematuria - Approximately 80-90% of patients; classic presentation Irritative bladder symptoms (eg, dysuria, urgency, frequency of urination) - 20-30% of patients Pelvic or bony pain, lower-extremity edema, or flank pain - In patients with advanced disease Palpable mass on physical examination - Rare (...) , rhabdosarcoma, carcinosarcoma, lymphoma, and small cell carcinoma. Leiomyosarcoma is the most common sarcoma of the bladder. most commonly occur in children. Carcinosarcomas are highly malignant tumors that contain a combination of mesenchymal and epithelial elements. Primary bladder lymphomas arise in the submucosa of the bladder. Except for lymphomas, all these rare bladder cancers carry a poor prognosis. Small cell carcinoma of the urinary bladder is a poorly differentiated, malignant neoplasm

2014 eMedicine.com

397. Benign Vulvar Lesions (Overview)

drug eruption is a cell-mediated allergic drug reaction typically recurring in the same site upon reexposure. Common causative agents include oral drugs such as nonsteroidal anti-inflammatory agents, acetaminophen, sulfonamides, tetracycline, and barbiturates. Fluconazole as a possible causative agent has also been recently reported. [ ] Atopic dermatitis Atopic dermatitis usually occurs in patients with a personal or family history of asthma, hay fever, childhood eczema, or dry skin and is related (...) ), located in the basement membrane of the skin. [ ] Mucosal lesions of the vulva occur less frequently and are less severe than other blistering disorders. [ ] A juvenile localized subtype of immunoglobulin G (IgG)–mediated bullous pemphigoid occurring in children in the first year of life and characterized by a self-limited nonscarring bullous pemphigoid–like process involving only the vulva has been described. [ ] Cicatricial pemphigoid Cicatricial pemphigoid is an autoimmune condition

2014 eMedicine.com

398. Augmentation Cystoplasty (Overview)

for an embryologic urinary defect as a child seek a healthier cosmetic and functional state. In other cases, adults have an acquired condition that is causing bladder dysfunction. Adults may present with symptoms very similar to those of children with congenital abnormalities. Again, surgery is indicated for adults with refractory symptoms and those with risk or progression of upper tract deterioration. Previous Next: Contraindications Patients who are unable or unwilling to perform life-long intermittent (...) pressure and improves continence. Adult patients should have good manual dexterity, proven by performing self-catheterization in front of the physician. In pediatric patients, the parents must be committed to catheterizing the child at least every 4-6 hours. Parents must be taught catheterization before surgery. Intermittent catheterization and anticholinergic management are usually used in combination to accomplish symptom-management goals, to create continence, to eliminate vesicoureteral reflux

2014 eMedicine.com

399. Nonneoplastic Epithelial Disorders of the Vulva (Follow-up)

, diaphragms Fixed drug eruption A fixed drug eruption is a cell-mediated allergic drug reaction typically recurring in the same site upon reexposure. Common causative agents include oral drugs such as nonsteroidal anti-inflammatory agents, acetaminophen, sulfonamides, tetracycline, and barbiturates. Fluconazole as a possible causative agent has also been recently reported. [ ] Atopic dermatitis Atopic dermatitis usually occurs in patients with a personal or family history of asthma, hay fever, childhood (...) of 180 kd now thought to be collagen XVII), located in the basement membrane of the skin. [ ] Mucosal lesions of the vulva occur less frequently and are less severe than other blistering disorders. [ ] A juvenile localized subtype of immunoglobulin G (IgG)–mediated bullous pemphigoid occurring in children in the first year of life and characterized by a self-limited nonscarring bullous pemphigoid–like process involving only the vulva has been described. [ ] Cicatricial pemphigoid Cicatricial

2014 eMedicine.com

400. Normal and Abnormal Puerperium (Follow-up)

), the American College of Obstetricians and Gynecologists (ACOG), and the United States Preventive Services Task Force recommend exclusive breastfeeding for the first six months of life. In 1991 The World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) launched a global program called The Baby-Friendly Hospital Initiation (BFHI) that aims to increase the numbers of infants who are exclusively breastfed worldwide. The BFHI program developed “Ten Steps to Successful Breastfeeding (...) by the ovaries is highly variable and is greatly influenced by breastfeeding the infant. The woman who breastfeeds her infant has a longer period of amenorrhea and anovulation than the mother who chooses to use formula. The mother who does not breastfeed may ovulate as early as 27 days after delivery. Most women have a menstrual period by 12 weeks; the mean time to first menses is 7-9 weeks. In the breastfeeding woman, the resumption of menses is highly variable and depends on a number of factors, including

2014 eMedicine.com

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