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Dysuria in Children

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421. Bladder, Cystitis

mucosa in the urachus. may be symptomatic or asymptomatic. Patients with bladder may present with symptoms of urgency, frequency, dysuria, hematuria, cloudy and offensive-smelling urine, or suprapubic discomfort. These symptoms may occur singly or in combination. The symptom of urgency results from the stimulation of the afferent arc of the micturition reflex; the offensive smell results from the bacterial conversion of urea to ammonia. Interstitial cystitis (bladder pain syndrome, Hunner ulcer (...) cystitis, also known as pseudotumoral cystitis, is an uncommon inflammatory process seen in children and adults. In children, it is a self-limiting condition that resolves spontaneously and that usually requires no treatment. Therefore, its recognition is important. Predisposing factors for eosinophilic cystitis include asthma, allergies, and eosinophilic gastroenteritis. Bladder biopsy reveals pancystitis and the presence of eosinophils, among other inflammatory cells. Radiographic findings

2014 eMedicine Radiology

422. Urinary Tract Infection, Female (Treatment)

genitourinary tract; who have no history of recent instrumentation; and whose symptoms are confined to the lower urinary tract. Uncomplicated cystitis is most common in young, sexually active women. Patients usually present with dysuria, urinary frequency, urinary urgency, and/or suprapubic pain. Treatment regimens for uncomplicated cystitis in nonpregnant women are provided in Table 1, below. Table 1. Treatment Regimens for Uncomplicated Cystitis in Nonpregnant Women [ ] First-line therapy trimethoprim (...) these agents have relatively poor efficacy and high rates of resistance. [ ] Previous Next: Adjunctive Therapy Patients with intense dysuria may obtain symptomatic relief from a bladder analgesic, such as phenazopyridine, to be used for 1-2 days. Avoid long-term use, as this agent may mask symptoms of therapeutic failure or recurrence. Many authors advise stressing the intake of plenty of fluids to promote a dilute urine flow. Previous Next: Fungal Infection In catheterized patients, removal

2014 eMedicine Emergency Medicine

423. Urinary Tract Infection, Male (Treatment)

filtration rate < 50). Treat the symptom of dysuria with phenazopyridine. [ , , , ] Unfortunately, the prevalence of uropathogens resistant to TMP-SMZ, nitrofurantoin, and first-generation cephalosporins has continued to rise. There are data that suggest overall resistance to TMP-SMZ is approximately 25% (range, 10-45%), based on the area of the country, and resistance to nitrofurantoin is slightly higher. Although studies have indicated that resistance to fluoroquinolones has been acceptably low, more (...) in childhood and repeated in late adolescence. Cystitis For the few men with uncomplicated cystitis, TMP-SMZ can be used in areas where resistant E coli number less than 20%; alternatively, a fluoroquinolone can be used. The length of treatment should be 7-10 days. Urethritis For urethritis, ceftriaxone (125mg IM as a single dose) treats penicillinase-producing N gonorrhoeae. Treatment for nongonococcal urethritis (NGU) should also be given (doxycycline 100mg PO bid for 7 days). Sexual partners should also

2014 eMedicine Emergency Medicine

424. Urogenital Reconstruction, Penile Hypospadias

below: Meatotomy is indicated at any age when the meatus caliber is reduced, causing dysuria. Correction of glanular hypospadias with distal urethra repositioning, creation of a symmetric glans (glanuloplasty), and preputium plasty is indicated in childhood or adolescence at the patient's request for cosmetic or psychological reasons. Correction of penile and penoscrotal hypospadias is indicated in childhood in patients younger than school age for the following reasons: To permit normalization (...) by its erectile tissue. The normal male urethra runs from the bladder through the penile shaft, ventrally to the corpora cavernosa, and sorts with the external urethral meatus at the tip of the glans. Previous Next: Contraindications Reconstruction of the urethra and restoration of the normal appearance of the genitalia is contraindicated in infancy because of the difficulty related to the small dimension of the structures. Previous References Smith ED. The hystory of hypospadias. Pediatr Surg Int

2014 eMedicine Surgery

425. Acute Abdomen and Pregnancy (Diagnosis)

(CT) examination is substantially below this level. [ ] During pregnancy, perform medically indicated diagnostic radiographic procedures when needed; when possible, however, consider other imaging procedures not associated with ionizing radiation instead of radiography. [ ] Because of the possible association of antenatal radiation exposure with childhood cancer, [ ] use ionizing radiation only when medically necessary, and minimize that exposure when possible without compromising patient care (...) for urolithiasis is approximately 1:1600. [ , ] For patient education information, see the , as well as and . History and physical examination Findings in urolithiasis include the following: Pain, usually in the flank - Almost always the presenting complaint Nausea and vomiting Dysuria Urgency Fever Gross hematuria History of a prior episode - In 25% of patients [ , ] Costovertebral angle tenderness - Almost always present Abdominal tenderness - Sometimes observed Workup Patients with urolithiasis may have

2014 eMedicine Surgery

426. Schistosomiasis, Bladder

areas are rising. In the complete absence of routine presymptomatic screening of these groups in developed countries, it is increasingly likely that patients with acute or chronic schistosomiasis will present to emergency departments (EDs) with a variety of complaints in nonendemic areas. [ , ] Pediatric and adolescent patients who have traveled or lived in endemic areas are at the highest risk for exposure to schistosomes and are at risk for serious long-term complications. These patients usually (...) . [ ] Acutely, patients with schistosomiasis may present with the following: Pruritic rash due to cercarial penetration into the skin Nonspecific symptoms such as fever, myalgias, and malaise Right upper quadrant abdominal pain Diarrhea Dysuria or hematuria Important laboratory findings include (1) eosinophilia and (2) hematuria and proteinuria, which is associated with urinary schistosomiasis. Manifestations of chronic schistosomiasis can also months or years after acute infection. Symptoms are nonspecific

2014 eMedicine Radiology

427. Surgical Treatment of Vaginal Cancer (Follow-up)

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

428. Cervical Cancer (Follow-up)

to alleviate symptoms from proctitis. Cystourethritis also can occur, leading to dysuria, frequency, and nocturia. Antispasmodics often are helpful for symptom relief. Urine should be examined for possible infection. If urinary tract infection (UTI) is diagnosed, therapy should be instituted without delay. Proper skin hygiene should be maintained for the perineum. Topical lotion should be used if erythema or desquamation occurs. Late sequelae of radiation therapy usually appear 1-4 years after treatment (...) series can be started as young as age 9 years. Catch-up vaccination is recommended for females aged 13-26 years who have not been previously vaccinated or who have not completed the full series. [ ] The 9vHPV vaccine may be offered as a 2-dose series for children and young adolescents aged 9-14 years. [ ] In the Costa Rica Vaccine Trial, researchers documented durable antibody responses after 1 dose (as opposed to the standard 3 doses) of the bivalent human papillomavirus (HPV) 16/18 L1 viruslike

2014 eMedicine.com

429. Dermatologic Diseases of the Male Genitalia: Nonmalignant (Follow-up)

with human papillomavirus (HPV) and Zoon balanitis has been identified. Clinical presentation/diagnosis Although the mean age at presentation is 53 years, patients aged 18-88 years are described in two series, and presentation in children as young as 12 years has been described. The men are uncircumcised in most series. Patients present with a solitary, glistening, sharply demarcated, large (2-3 cm), erythematous, speckled patch on the glans or inner prepuce. Rarely, multiple patches can erode (...) and outcome (5%) cream is recommended, with application to the entire skin surface below the chin. The cream should be left on for 8-14 hours (overnight) and then washed off. Second-line therapy includes the use of 1% lotion/cream or oral . Ivermectin may be repeated in 2 weeks. Lindane is not recommended for pregnant women or children younger than 2 years. Use lindane as a single dose (do not repeat). [ ] Antipruritic agents may be helpful in reducing discomfort related to pruritus. All household members

2014 eMedicine.com

430. Cyclospora (Follow-up)

findings returned to normal. These findings suggest, but do not prove, Cyclospora -related reversible gallbladder pathology. Reactive arthritis syndrome (RAS): RAS developed in a 31-year-old man with documented Cyclospora infection 5 months after the exposing event and approximately 2 months after the absence of Cyclospora on intestinal biopsies. He had not received TMP-SMZ because of sulfa allergy, and no other antibiotic was prescribed. At the time of the RAS diagnosis (dysuria, negative urinalysis (...) YR. Cyclospora cayetanensis in a Pediatric Hospital in Morelia, México. Am J Trop Med Hyg . 2014 Sep 3. 91(3):537-40. . . Thima K, Mori H, Praevanit R, Mongkhonmu S, Waikagul J, Watthanakulpanich D. Recovery of Cyclospora cayetanensis among asymptomatic rural Thai schoolchildren. Asian Pac J Trop Med . 2014 Feb. 7(2):119-23. . Liu H, Shen Y, Yin J, Yuan Z, Jiang Y, Xu Y, et al. Prevalence and genetic characterization of Cryptosporidium, Enterocytozoon, Giardia and Cyclospora in diarrheal

2014 eMedicine.com

431. Cystectomy, Radical (Follow-up)

. Advantages and Disadvantages of Intestinal Segments Used for Urinary Diversion Segment Advantages Disadvantages Stomach Can be used in patients with renal failure, hepatic failure, acidosis, and pelvic radiation; no mucus production Hypokalemic hypochloremic metabolic alkalosis, hematuria dysuria syndrome due to acid irritation of the urothelium, concern for increased secondary malignancy Jejunum N/A Hyperkalemic hypochloremic metabolic acidosis, hyponatremia, osteomalacia (Avoid if at all possible

2014 eMedicine.com

432. Genital Herpes in Pregnancy (Follow-up)

of Obstetrics and Gynecologists (Washington, DC) for speaking and teaching; Received honoraria from National Institute of Child Health and Human Development Pediatric and Adolescent Gynecology Research Thi. Chief Editor Ronald M Ramus, MD Professor of Obstetrics and Gynecology, Director, Division of Maternal-Fetal Medicine, Virginia Commonwealth University School of Medicine Ronald M Ramus, MD is a member of the following medical societies: , , , Disclosure: Nothing to disclose. Additional Contributors (...) to herpes simplex virus 2 (HSV-2). Approximately 22% of pregnant women are infected with HSV-2 and 2% of women acquire genital herpes in pregnancy. Approximately 1500-2000 new cases of neonatal HSV infection are diagnosed each year. The incidence of neonatal herpes varies considerably in international studies (about 1:3,200 births in the US and 1:60,000 in the UK). Approximately 80% of infected infants are born to mothers with no reported history of HSV infection. [ ] Untreated neonatal HSV infection

2014 eMedicine.com

433. Epididymal Tuberculosis (Follow-up)

appearance) with . Severe cases involve the entire bladder wall, where deep layers of muscle are eventually replaced by fibrous tissue, thus producing a thick fibrous bladder. Tubercles are rare in the bladder; if present, they usually appear at the ureteral orifice. Malignancy should be considered with any isolated tubercles away from the ureteral orifices. Epididymal and testicular TB The higher frequency of isolated epididymal TB lesions in children favors the possibility of hematologic spread (...) increased frequency of urination (during the day initially but at night later in the disease course), dysuria, frank pain, suprapubic pain, blood or pus in the urine, and fever. Urinary urgency is relatively uncommon unless the bladder is extensively involved. Patients with GUTB may also present with a painful testicular swelling, perianal sinus, or genital ulcer. Unexplained infertility in both men and women is sometimes attributable to GUTB. [ ] Physicians have also diagnosed endometrial TB while

2014 eMedicine.com

434. Augmentation Cystoplasty (Follow-up)

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

435. Surgical Treatment of Vaginal Cancer (Diagnosis)

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

436. Streptococcus Group B Infections (Diagnosis)

bacteruria to cystitis and pyelonephritis with bacteremia): Fever, dysuria, flank pain, or pelvic pain See for more detail. Diagnosis Examination in patients with GBS infection may demonstrate the following findings: Lung consolidation, pleural effusion Tachypnea Tachycardia, murmur, evidence of heart failure Hypotension Headache, nuchal rigidity Confusion, altered mental status, neurologic dysfunction Evidence of an embolic event, phlebitis, Splenomegaly Vascular insufficiency of the lower extremity (...) B streptococcal disease from that caused by other pathogens. Pneumonia with bacteremia is common, while meningitis is less likely. Late group B streptococcal neonatal sepsis is defined as infection that presents between one week postpartum and age 3 months. Late disease commonly involves group B Streptococcus serotype III, typically characterized by bacteremia and meningitis. The absence of antibody to group B streptococci in infants is a risk factor for infection. Because antibodies to group B

2014 eMedicine.com

437. Urinary Tract Infection, Females (Follow-up)

genitourinary tract; who have no history of recent instrumentation; and whose symptoms are confined to the lower urinary tract. Uncomplicated cystitis is most common in young, sexually active women. Patients usually present with dysuria, urinary frequency, urinary urgency, and/or suprapubic pain. Treatment regimens for uncomplicated cystitis in nonpregnant women are provided in Table 1, below. Table 1. Treatment Regimens for Uncomplicated Cystitis in Nonpregnant Women [ ] First-line therapy trimethoprim (...) these agents have relatively poor efficacy and high rates of resistance. [ ] Previous Next: Adjunctive Therapy Patients with intense dysuria may obtain symptomatic relief from a bladder analgesic, such as phenazopyridine, to be used for 1-2 days. Avoid long-term use, as this agent may mask symptoms of therapeutic failure or recurrence. Many authors advise stressing the intake of plenty of fluids to promote a dilute urine flow. Previous Next: Fungal Infection In catheterized patients, removal

2014 eMedicine.com

438. Urinary Tract Infection, Males (Follow-up)

filtration rate < 50). Treat the symptom of dysuria with phenazopyridine. [ , , , ] Unfortunately, the prevalence of uropathogens resistant to TMP-SMZ, nitrofurantoin, and first-generation cephalosporins has continued to rise. There are data that suggest overall resistance to TMP-SMZ is approximately 25% (range, 10-45%), based on the area of the country, and resistance to nitrofurantoin is slightly higher. Although studies have indicated that resistance to fluoroquinolones has been acceptably low, more (...) in childhood and repeated in late adolescence. Cystitis For the few men with uncomplicated cystitis, TMP-SMZ can be used in areas where resistant E coli number less than 20%; alternatively, a fluoroquinolone can be used. The length of treatment should be 7-10 days. Urethritis For urethritis, ceftriaxone (125mg IM as a single dose) treats penicillinase-producing N gonorrhoeae. Treatment for nongonococcal urethritis (NGU) should also be given (doxycycline 100mg PO bid for 7 days). Sexual partners should also

2014 eMedicine.com

439. Condyloma Acuminatum (Follow-up)

. In more than one half of children with anogenital warts, the lesions are a manifestation either of viral inoculation at birth or of incidental spread of cutaneous warts. Such cases often are caused by nongenital HPV types. The diagnosis of genital warts in a child requires that the clinician report suspected abuse to begin an evaluation process that may or may not confirm sexual abuse. [ , ] Neonates and infants with laryngeal papillomatosis Pregnant women with genital warts can transmit the virus (...) . Patients with perianal warts, those who are HIV positive, and those with a history of receptive anal intercourse are at increased risk for anal HGSIL. There is no direct evidence to suggest that this would progress to invasive anal cancer, as lesions of the cervix are capable of doing. Nonetheless, penile, vulvar, vaginal, anal carcinomas, and head and neck cancers have been linked to HPV infection. [ ] Children with anogenital warts Anogenital warts are rare in the general pediatric population

2014 eMedicine.com

440. Reactive Arthritis (Treatment)

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 Emergency Medicine

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