Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010
CHAPTER 13 – GENITOURINARY SYSTEM
First Nations and Inuit Health Branch (FNIHB) Pediatric Clinical Practice Guidelines for Nurses in Primary Care.
The content of this chapter has been revised August 2010.
Table of Contents
INTRODUCTION.....................................................................................................13–1
ASSESSMENT OF THE GENITOURINARY SYSTEM...........................................13–1
History of Present Illness and Review of Systems............................................13–1
Physical Examination........................................................................................13–1
COMMON PROBLEMS OF THE GENITOURINARY SYSTEM..............................13–3
Glomerulonephritis............................................................................................13–3
Hydrocele (Physiologic)....................................................................................13–5
Prepubescent Vaginal Discharge......................................................................13–6
Urinary Incontinence (Enuresis)........................................................................13–8
Urinary Tract Infection.......................................................................................13–8
EMERGENCY PROBLEMS OF THE MALE GENITAL SYSTEM..........................13–11
Testicular Torsion............................................................................................13–11
SOURCES.............................................................................................................13–13

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INTRODUCTION
For more information on the history and physical
examination of the genitourinary system in older
children and adolescents, see the chapters,“Urinary
and Male Genital Systems” and “Women’s
Health and Gynecology” in the adult clinical
practice guidelines.
ASSESSMENT OF THE GENITOURINARY SYSTEM
The genitourinary (GU) system may be affected by
congenital abnormalities, inflammation, infection,
other body systems or diseases of the kidneys.
HISTORY OF PRESENT ILLNESS
AND REVIEW OF SYSTEMS
Newborns and infants with urinary tract disorders
and diseases may present with the following signs
and symptoms:
1
––Pallor
––Fever
––Jaundice
––Seizures
––Dehydration
––Poor feeding
––Vomiting
––Excessive thirst
––Frequent urination
––Screaming on urination
––Poor urine stream
––Foul-smelling urine
––Enlarged kidney or bladder
––Persistent diaper rash
––Failure to thrive
––Rapid respirations (acidosis)
––Respiratory distress
––Spontaneous pneumothorax
or pneumomediastinum
The following signs and symptoms are those most
commonly associated with urinary tract infection
(UTI) in children:
2

––Fever
––Enuresis (bed-wetting)
––Incontinence (new onset)
––Dysuria
––Hematuria
––Frequency
––Urgency
––Change in colour or cloudy, foul-smelling urine
––Abdominal, suprapubic, flank or back pain or
tenderness
––Scrotal or groin pain
––Genital sores, swelling, discolouration
––Lack of circumcision
––Toilet-training problems
––Irritability
––Poor feeding
The following symptoms are associated with
nephrotic syndrome and glomerulonephritis:
––Swelling (for example, ankles, around eyes)
––Headaches
––Nosebleeds (an occasional symptom of
hypertension, but nosebleeds also occur frequently
in normal children)
––Hematuria
––Smoky or coffee-coloured urine
––Decreased urinary output
––Pallor
––Weight gain
A complete history of the GU system should include
questions related to:
––Sexual activity (for adolescents)
––Problems related to inappropriate touching
by others (that is, sexual abuse)
Children must be asked such questions with sensitivity
and without the use of leading questions. The parents
or caregiver can be asked about these topics directly.
PHYSICAL EXAMINATION
VITAL SIGNS
––Temperature
––Heart rate
––Respiratory rate
––Blood pressure

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URINARY SYSTEM (ABDOMINAL
EXAMINATION)
3
For full details, see “Physical Examination” of the
abdomen in the pediatric chapter “Gastrointestinal
System”.
INSPECTION
––Abdominal contour, looking for asymmetry
or distention (a sign of ascites)
––Abdominal pulsations
––Peripheral vascular irregularities
––Masses
PERCUSSION
––Determine organ size
––Liver span (may be increased in
glomerulonephritis)
––Ascites (dull to percussion in flanks when child
is supine; location of dullness shifts when child
changes position)
––Tenderness over costovertebral angle
PALPATION
––Size of liver and any tenderness because of
congestion
––Identify local areas of pain or mass lesions
––Kidneys are often palpable in infants, the right
kidney being most easily “captured;” perform deep
palpation to determine kidney size and tenderness
(place one hand under the back and the other hand
on the abdomen to try to “capture” the kidney
between the hands)
MALE GENITALIA
Perform examination with the child supine and,
if possible, in the standing position.
Penis
4
Inspection:
––In the neonate, examination should focus upon
possible congenital anomalies
––Penile length
––Foreskin anatomy
––Location of the urethral meatus
––Scrotal anatomy (including rugae)
––Presence and location of the testes
––Presence of abnormal scrotal or inguinal masses
––Position of urethra (for example, epispadias,
hypospadias)
––Discharge at urethra (distinguish poor hygiene
from urethritis)
––Inflammation of foreskin or head of penis
(sign of balanitis)
Palpation:
––Foreskin adherent at birth normally
––In 90% of uncircumcised male children, the
foreskin becomes partially or fully retractable
by 5 years of age
4
––Inability to retract foreskin (phimosis)
––Inability of retracted foreskin to return to normal
position (paraphimosis)
Scrotum and Testicles
Inspection:
––Scrotum may appear enlarged
––Check penile and scrotal skin for any unusual
lesions
––Check for edema (a sign of glomerulonephritis),
hydrocele (transillumination should be possible),
hernia, varicocele or abnormal masses
Palpation:
––Cremasteric reflex (absent in testicular torsion)
––Testicular size, position, consistency, shape and
descent into scrotum
––Testicular tenderness: consider torsion or
epididymitis (pain is actually in the epididymis,
not the testicle)
––Swelling in inguinal canal: consider hernia or
hydrocele of spermatic cord
––Mass in scrotum
For information about examining the adolescent male,
see “Genitourinary and Male Genital Systems” in the
adult clinical practice guidelines.
FEMALE GENITALIA
The clinician must be sensitive regarding the
genitourinary examination of the older female child.
Male providers should request the presence of a parent
or delegate during the examination. At the onset of
the examination of the genitalia, explain to the patient
why examination of the area is needed and how it
will be performed, including what instruments, if
any, will be used.
––Child should be in supine frog-leg position for
examination

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––Do not perform an internal vaginal examination in
a prepubescent child or an adolescent who is not
sexually active
––Spread labia by applying gentle traction toward
examiner and slightly laterally to visualize the
vaginal orifice
Inspection
––Vulvar irritation
––Erythema (in prepubescent girls, the labia normally
appears redder than in adult women because the
tissue is thinner)
––Ulcerative or inflammatory lesions
––Urethral irritation (sign of UTI)
––Vaginal discharge
––Bleeding
––Enlargement of vaginal orifice
––History and observations should concur or may
indicate sexual abuse
For information about examining the adolescent
female, see “Assessment of the Female Reproductive
System” in the adult chapter “ Women’s Health and
Gynecology”.
COMMON PROBLEMS OF THE GENITOURINARY SYSTEM
GLOMERULONEPHRITIS
Disease in which there is immunologic or toxic
damage to the glomerular apparatus of the kidneys.
It can occur acutely (acute glomerulonephritis) or
it may have a chronic or insidious onset (chronic or
progressive glomerulonephritis).
ACUTE POST-STREPTOCOCCAL
GLOMERULONEPHRITIS
5
Acute post-streptococcal glomerulonephritis
(APSGN) is caused by glomerular immune complex
disease induced by specific nephritogenic strains
of group A beta-hemolytic Streptococcus. It is the
most common of the noninfectious renal diseases in
childhood. APSGN can occur at any age but primarily
affects early school-aged children, with a peak age
of onset of 6 to 7 years. It is uncommon in children
under age 2.
CAUSES
––Usually secondary to previous streptococcal
infection (for example, of the throat or skin)
––Follows pharyngitis or otitis by 1–3 weeks
––Lag time after skin infections is variable (can be
up to 3 weeks)
HISTORY
––Acute onset
––Usually history of pharyngitis or impetigo about
10 days before the abrupt onset of dark urine
––Acute phase lasts about 1 week
SYSTEMIC SYMPTOMS
––Anorexia
––Periorbital edema
––Decreased urination
––Smoky or coffee-coloured urine
––Mild to severe hypertension
––Abdominal pain
––Fever
––Headache
––Lethargy
––Fatigue, malaise
––Weakness
––Rash, impetigo
––Joint pain
––Weight loss
PHYSICAL FINDINGS
The physical findings are variable and may include
the following:
––Edema (in about 85% of cases)
6

––Hypertension (in about 80% of cases)
6
––Hematuria (30% of children have gross hematuria)
6
––Proteinuria
––Oliguria
––Renal failure (to variable degree)
––Congestive heart failure
––Hypertensive encephalopathy (rare)
Edema, hypertension and hematuria are the most
common and most worrisome symptoms.

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DIFFERENTIAL DIAGNOSIS
––Other forms of glomerulonephritis, which have
many similar features (distinguished by laboratory
tests, renal biopsy and other diagnostic methods)
––Acute hemorrhagic cystitis (no edema,
hypertension, renal failure; does involve dysuria,
frequency, urgency)
––Acute interstitial nephritis
––Antiglomerular basement membrane disease
––Cryoglobulinemia
––Nephritis, lupus
COMPLICATIONS
––Acute renal failure
––Congestive heart failure
––Pulmonary edema
––Sepsis
––Hyperkalemia
––Severe hypertension
––Chronic renal failure
DIAGNOSTIC TESTS
The diagnosis is made on a clinical basis and is
confirmed by the following tests:
––Urinalysis (hematuria, proteinuria)
––Hemoglobin decreased (mild anemia)
––WBC count increased
––Recent throat swab positive for Streptococcus A
infection
MANAGEMENT
Goals of Treatment
––Prevent, if possible, by early treatment of all
streptococcal infections (skin and pharyngeal)
––Prevent or treat complications
Appropriate Consultation
Consult a physician immediately if you suspect
this disorder.
Nonpharmacologic Interventions
While awaiting transfer:
––Bed rest
––Fluid restriction (to 60 mL/kg per day
+ urine losses)
––Sodium-restricted diet
––Correction of electrolyte imbalance
Pharmacologic Interventions
None, unless complications develop. Treat
complications only on physician’s instruction.
In patients with evidence of persistent infection
(that is, those with positive cultures), the underlying
streptococcal infection can be treated with penicillin
or erythromycin.
Monitoring and Follow-Up
while Awaiting Transfer
––Fluid restriction (to 60 mL/kg per day
+ urine losses)
––Monitor blood pressure and vital signs
––Daily weight
––Respiratory status
––Renal function
––Monitor intake and output
––Watch for major life-threatening problems,
such as acute renal insufficiency with electrolyte
abnormalities, fluid overload, pulmonary edema,
congestive heart failure, acute hypertension
Monitoring and Follow-Up over the Long Term
––Will depend on cause and type of condition
––Post-streptococcal glomerulonephritis usually
has no long-term sequelae, but other types
of glomerulonephritis may have long-term
complications, including recurrence and chronic
renal failure
––Consulting specialist will provide instructions
for surveillance
Referral
Medevac.
CHRONIC OR PROGRESSIVE
GLOMERULONEPHRITIS
5
Chronic glomerulonephritis (CGN) is characterized
by irreversible and progressive glomerular and
tubulointerstitial fibrosis, ultimately leading to
a reduction in the glomerular filtration rate and
retention of uremic toxins. In cases where CGN is not
associated with other diseases, it may go undetected
for years and be relatively asymptomatic until kidney
destruction produces a marked reduction in kidney
function. Consequently, the disease is more common
in adolescents than in younger children.

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HYDROCELE (PHYSIOLOGIC)
7,8
A hydrocele is a collection of peritoneal fluid between
the parietal and visceral layers of the tunica vaginalis
testis or along the spermatic cord.
Hyroceles are the most common cause of scrotal
swelling and are relatively common in newborns,
appearing in approximately 6% of full-term male
neonates. They rarely occur in infant girls, in which
they would present as a firm swelling in the groin.
Hydroceles may be communicating or
noncommunicating.
CAUSES
Communicating Hydroceles
––Usually develop as a result of failure of the
processus vaginalis to close during development;
the fluid around the scrotum is peritoneal fluid
Noncommunicating Hydroceles
––Fluid accumulation may be caused by infection,
trauma, tumour, an imbalance between the
secreting and absorptive capacities of scrotal
tissues or an obstruction of the lymphatic or venous
drainage in the spermatic cord
––This leads to a displacement of fluid in the scrotum,
outside the testes
––Subsequent swelling leads to reduced blood flow
to the testes
HISTORY
––Painless swelling in scrotum
––Congenital or acquired
––Hydroceles that are present in newborns, whether
communicating or noncommunicating, usually
resolve spontaneously by the first birthday, unless
they are accompanied by an inguinal hernia
––Swelling may fluctuate in size
PHYSICAL FINDINGS
––Should be able to palpate an upper border of
the swelling
––Soft, nontender fullness within the hemiscrotum
––Transillumination of the swelling should reveal
a homogenous glow without internal shadows
––Inguinal hernia may also be present
––Examination of patients with hydroceles should
include palpation of the entire testicular surface
for findings of epididymitis, orchitis, testicular
torsion, torsion of the appendix testis or appendix
epididymis, trauma or tumour as the primary etiology
Hydrocele of the spermatic cord may also be seen:
––Painless cystic swelling along the inguinal canal
––Swelling may transilluminate
DIFFERENTIAL DIAGNOSIS
––Enlargement of groin node
––Trauma
––Cystic lesion
––Hematoma
––Neoplasm
COMPLICATIONS
––Slight increase in risk of inguinal hernia
––Testicular atrophy
––Epididymitis
DIAGNOSTIC TESTS
––The diagnosis of hydrocele can be made by
physical examination and transillumination of the
scrotum demonstrating a cystic fluid collection
MANAGEMENT
Goals of Treatment
––Observe until condition resolves spontaneously
or surgical referral becomes necessary
Appropriate Consultation
Consult physician in the following circumstances:
––Diagnosis is unclear
––There are signs of complications (for example,
infection)
––There is an associated inguinal hernia
Nonpharmacologic Interventions
––Scrotal elevation
––Explain to parents or caregiver the pathophysiology
of the defect
––Reassure the parents or caregiver
––Advise parents or caregiver to return to the clinic
if the mass enlarges
Monitoring and Follow-Up
Reassess every 3 months until resolution occurs or
referral becomes necessary.

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Referral
Referral to a physician may be necessary if there
are signs of complications (for example, if there is
an associated inguinal hernia) or resolution does not
occur when expected (by 1 year of age).
Surgical treatment is considered in the following
circumstances:
––No signs of resolution by age 1 year (surgery may
be delayed until age 2 or 3 in some circumstances)
––Hernias are associated with the hydrocele
PREPUBESCENT VAGINAL
DISCHARGE
9
For vaginal discharge in adolescents,
see “Vulvovaginitis” in the adult chapter
“Communicable Diseases”.
DEFINITION
Physiologic discharge:
––Mucoid
––Nonmalodorous
––Seen in newborns and premenarchal girls
(see “Tanner stage II and III” in the chapter,
“Adolescent Health”)
––Normal vaginal secretions are often increased
midcycle in adolescents
Any other discharge is a symptom of underlying
problems.
Vaginal discharge is uncommon in girls < 9 years old.
CAUSES AND ASSOCIATED ORGANISMS
––Poor hygiene (Escherichia coli)
––Moisture (especially resulting from synthetic fibre
underwear, tight clothing, wet swimsuits, obesity)
––Chemical irritants (bubble baths), local trauma
––Poor estrogenization is a common factor that
makes the vulvar tissues vulnerable to irritation
and infection
––Autoinoculation from associated upper respiratory
tract infection (URTI) (Haemophilus influenzae,
group B Streptococcus) or skin infections
(Staphylococcus)
––Pinworms (E. coli)
––Foreign body (associated with E. coli)
––Other skin diseases affecting the genital area
(for example, eczema)
––Specific infection: Candida, Chlamydia, Neisseria
gonorrhoeae, Trichomonas (uncommon),
bacterial vaginosis
If N. gonorrhoeae or Chlamydia is the cause of the
discharge and the child is underage for consensual sex
(that is, < 16 years), sexual abuse must be considered.
HISTORY
––Various degrees of perineal discomfort or itching
––Vaginal discharge – note onset, quantity, colour,
type, odour, consistency and duration
––Dysuria
––Enuresis
––Frequency
––Recent medications, especially antibiotics
––Associated illnesses (for example, URTI, skin
problems, pinworms)
––Hygiene
––Use of harsh soaps and bubble bath
––Tight-fitting or nylon underwear or clothing
––Possible sexual abuse
PHYSICAL FINDINGS
Do not perform a vaginal speculum examination
or restrain the child.
––Suboptimal general or perineal hygiene
––Signs of URTI or skin disease
Labial Irritation
––Consider problems with perineal hygiene or local
chemical irritation (soaps, moisture)
––Candida infection
––Sexual abuse
Marked Erythema
Consider Candida infection
Vaginal Discharge
––May be nonspecific
––Thick, white, cheesy: possibly Candida
––Frothy, green: likely bacterial, Trichomonas
––Dark brown, foul smelling: possibly from
a foreign body
Foreign Body
––May be visualized better if child is in knee-chest
position
––May be palpated while doing a rectal examination

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DIFFERENTIAL DIAGNOSIS
Noninfectious
––Poor hygiene
––Chemical irritation (for example, from bubble bath)
––Foreign body
––Trauma
––Atopic dermatitis
––Psoriasis
––Seborrhea
––Labial adhesions
––Systemic diseases (for example, Kawasaki
or Crohn’s)
Infectious
––Group A Streptococcus infection
––Nonspecific bacterial infection
––Pinworms
––Candida (less common)
––Sexually transmitted infection (STI) (consider
sexual abuse)
COMPLICATIONS
The complications depend on the underlying cause.
––Localized perineal irritation
––UTI
––Abdominal pain (with pinworms or UTI)
––Vaginitis
––Bleeding (from trauma)
––Labial adhesions
DIAGNOSTIC TESTS
If child is cooperative, attempt to swab vaginal orifice
(using small, calcium alginate–tipped swab); avoid
touching the hymenal edge. Swab for Chlamydia,
N. gonorrhoeae, culture and sensitivity and hanging
drop, in that order.
––Urine for routine and microscopic analysis
––Urine for culture and sensitivity
––pH of vaginal secretions
Hormonal levels may be indicated in females with dry
vaginal orifice. Consult physician or nurse practitioner
if this is a finding.
MANAGEMENT
Management depends on cause.
Goals of Treatment
––Identify and correct underlying cause
Appropriate Consultation
Consult a physician if the child is febrile or has
abdominal pain, or if you suspect sexual abuse.
Consider sexual abuse if you suspect nonexploitative
sexual activity with a partner more than 2 years
older than themselves. Refer to the chapter “Child
Maltreatment” for age-related definitions of child
abuse. Also refer to the chapter “Child Maltreatment”
for provincial legislation on reporting maltreatment
and abuse in children.
Nonpharmacologic and
Pharmacologic Interventions
For poor hygiene
––Improve perineal hygiene
––Avoid bubble baths
––Wipe from front to back, but avoid scrubbing
genitalia
For foreign body
In an older child who can cooperate, remove the
foreign body if visible and within easy reach; otherwise
consult a physician about options for removal.
amoxicillin (Amoxil), 50 mg/kg/day, divided tid, PO
for 7–10 days while awaiting removal of foreign body
For pinworms
See “Pinworms” in Chapter 18, “Communicable
Diseases”.
For candidal infection
clotrimazole 1% cream PV qd x 7 days
For trichomonal infection
for age > 13 years, metronidazole (Flagyl),
2 g PO stat
for age < 13 years, consult a physician
regarding dosage
For bacterial vaginosis
10
Preferred regimen:
metronidazole (Flagyl, generics), 500 mg PO bid
x 7 days
Alternative regimen:
metronidazole (Flagyl, generics), 2 g PO stat
For STI
Consult a physician, a certified sexual health
nurse or a nurse practitioner if you suspect an STI
in a preadolescent child. Refer to and follow the

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“Canadian Guidelines on Sexually Transmitted
Infections” (available at: http://www.phac-aspc.gc.ca/
std-mts/sti-its/pdf/sti-its-eng.pdf).
If the cause of the discharge is uncertain, send samples
for culture and sensitivity and consult a physician or
nurse practitioner for therapeutic options.
Report as suspected sexual abuse all cases of
gonorrhea and Chlamydia infection in girls where the
legal definition of sexual abuse is met. Refer to “Child
Maltreatment” for age-related definitions of child
abuse. Other cases of vaginitis may be reportable,
depending on the circumstance.
URINARY INCONTINENCE
(ENURESIS)
11,12
Urinary incontinence is the uncontrolled leakage
of urine, which can be continuous or intermittent.
Incontinence is twice as common in boys as in girls.
12
CAUSES
11
Night-time incontinence:
––Slower physical development
––Excessive output of urine during sleep
––Anxiety
––Genetics
––Obstructive sleep apnea
Daytime incontinence:
––Overactive bladder
––Infrequent voiding
––Small bladder capacity
––Structural problems
––Anxiety-causing events
––Drinks and foods that contain caffeine
HISTORY
––Primary enuresis is wetting in a child who has
never been dry for at least 6 months
––Secondary enuresis is wetting that begins after
at least 6 months of dryness
––Nocturnal enuresis is wetting that usually occurs
during sleep
––Diurnal enuresis is wetting when awake, also
called daytime incontinence
DIFFERENTIAL DIAGNOSIS
––Urinary tract infection
COMPLICATIONS
11
––There is a clear association between voiding
dysfunction and urinary tract infection (UTI)
––Voiding dysfunction may predispose children
to recurrent UTI and renal injury
––The risk of bladder colonization and UTI is
increased in children with incomplete bladder
emptying due to dysfunctional voiding or
underactive bladder
MANAGEMENT
Goals of Treatment
––Rule out other causes (for example, infection)
Nonpharmacologic Interventions
––Moisture alarms
––Bladder training and related strategies:
––exercises for strengthening and coordinating
muscles of the bladder and urethra
––determining bladder capacity
––drinking less fluid before sleeping
––developing routines for waking up
––urinating on a schedule (for example,
every 2 hours)
––avoiding caffeine or other foods or drinks
that may contribute to incontinence
Pharmacologic Interventions
A complete urological review in consultation with a
physician is required before medication is prescribed
for urinary incontinence.
URINARY TRACT INFECTION
See also “Commons Problems of the Urinary System”
in the adult chapter “Urinary and Male Genital
System”.
Bacterial invasion of the genitourinary (GU) tract with
resulting infection.
––Cystitis: infection affecting only the lower GU tract
(for example, the bladder)
––Pyelonephritis: ascending infection involving
the upper GU tract (for example, the ureters and
kidneys)
Urinary tract infection (UTI) is the most common
genitourinary disease in children. The prevalence
of UTI is highest in boys younger than 1 year and
girls younger than 4 years. Uncircumcised male
infants, when presenting with fever, have a four- to

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eight‑fold higher prevalence of UTI than circumcised
male infants. Female infants have a two- to four-fold
higher prevalence of UTI than male infants. This
has been presumed to be the result of the shorter
female urethra. As for uncircumcised male infants,
the higher incidence is thought to be related to the
mucosal surface of the uncircumcised foreskin
being more likely to bind uropathogenic bacteria. In
uncircumcised boys, a possible partial obstruction
of the urethral meatus by a tight foreskin may be the
explanation for the higher incidence of UTI.
13
An
increased incidence of UTI is observed in adolescents,
notably in those who are sexually active.
14
CAUSES
Bacterial invasion by one of the following
organisms:
14
––Escherichia coli in over 80% of cases
15

––Staphylococcus aureus
––Enterococcus spp.
––Klebsiella spp.
––Proteus mirabilis
––Pseudomonas spp.
––Haemophilus spp.
––Coagulase-negative staphylococci
Predisposing factors:
––Congenital GU tract abnormalities, for example,
vesicoureteral reflux, short urethra (however,
most children with UTI have a normal GU tract)
––Perineal fecal contamination because of inadequate
hygiene
––Infrequent voiding or urinary stasis
––Perianal infections
––Sexual activity
HISTORY
The history depends on the child’s age.
Neonates and Infants
16
––Primarily nonspecific, non-urinary symptoms
––May present with septicemia
––Fever
––Irritability (“colic”)
––Poor feeding
––Vomiting
––Loose stools
––Jaundice (particularly in neonates)
––Hypothermia
––Failure to thrive
––Decreased activity, lethargy
Younger Children (≤ 3 Years Old)
––Abdominal complaints including pain
––Suprapubic tenderness
––Fever – infants and children younger than 2 years
can present with fever as the sole manifestation of
UTI
17
––Frequency, urgency, dysuria, enuresis
––Urinary retention
––Lack of circumcision in boys
18

Older Children (>3 Years)
19
––May present with chronic urinary symptoms –
incontinence, lack of proper stream, frequency,
urgency, withholding maneuvers
––Chronic constipation
––History of previous UTI
––Fever
––Dysuria
––Flank or back pain
––In sexually active girls, barrier contraception
with spermicidal agents predisposes to UTI
PHYSICAL FINDINGS
––Fever (may be absent in simple cystitis)
––Suprapubic tenderness (in cystitis)
––Tenderness of abdomen, flank and costovertebral
angle (more likely with pyelonephritis)
––Hematuria
Be sure to assess hydration status.
DIFFERENTIAL DIAGNOSIS
Distinguish between cystitis and pyelonephritis.
Infection of the Lower GU Tract (Cystitis)
––Urethral irritation (for example, bubble bath,
scented soaps or powders)
––Urethral trauma
––Diabetes mellitus
––Masses adjacent to bladder
Infection of the Upper GU
Tract (Pyelonephritis)
––Gastroenteritis
––Pelvic inflammatory disease (PID)
(Chandelier sign with bimanual examination)
––Tubo-ovarian abscess

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––Appendicitis
––Ovarian torsion
COMPLICATIONS
––Recurrent UTI
––Sepsis, especially in neonates and infants
< 6 months of age
––Renal damage leading to adult hypertension,
renal failure
DIAGNOSTIC TESTS
Urinalysis for routine and microscopic examination
(midstream specimen for older children, catheter
specimen for infants).
Bagged urine specimens are of no value in diagnosing
a UTI in infants, even if positive.
––White blood cells (WBCs)
––Bacteriuria
––Hematuria (blood in urine)
––Positive for nitrates (although UTI can occur with
organisms that do not produce nitrate)
Urine for culture and sensitivity:
––Preferably a first morning specimen; in infants,
use a clean catheter specimen
––If multiple organisms present on culture, suspect
contamination, not true infection
––Complete blood count, serum creatinine and blood
cultures should be obtained if the child is febrile
and systemically unwell
RADIOLOGIC EVALUATION
20,21
––A renal and bladder ultrasound is the least invasive
method to visualize the kidneys and bladder,
and should be used primarily to screen for an
obstruction or abscess when resolution of UTI
symptoms is slower than expected
––Infants and young children with a UTI should
undergo radiologic imaging to examine the urinary
tract for structural abnormalities if there is no
significant improvement of symptoms after 2 days
of antimicrobial therapy
MANAGEMENT
Lower GU infections (for example, cystitis) are
generally less severe and usually managed on an
outpatient basis. Pyelonephritis is more severe
and may require hospital care for intravenous (IV)
antibiotics. The decision about hospitalization
depends on the child’s age and the severity of the
clinical condition.
Goals of Treatment
––Eradicate infection
––Prevent recurrence
––Identify underlying factors
Appropriate Consultation
Consult a physician for any of the following:
––Recurrent urinary tract infections where
imaging (renal ultrasound or scan, voiding
cystourethrogram) may be required
19

––Neonatal infections, for which medevac is
required; these are often associated with bacterial
sepsis and require IV treatment
––Suspected pyelonephritis, for which child may be
admitted to hospital (depends on age and severity
of illness)
CYSTITIS
Nonpharmacologic Interventions
––Increase rest if febrile
––Increase oral fluids to promote urine flow
Pharmacologic Interventions
Do not treat as UTI unless results of appropriately
collected urine specimens support the diagnosis
(for example, positive for nitrates or WBCs).
Antibiotics:
trimethoprim-sulfamethoxazole (TMP-SMX,
Septra and generics)
The dose is calculated on the basis of the
trimethoprim component not sulfamethoxazole
Suspension contains TMP 40 mg / SMX 200 mg
per 5 mL
trimethoprim-sulfamethoxazole: 5–10 mg TMP/kg
per day divided bid, PO for 7–10 days
Consult a physician for choice of antibiotics if child
is allergic to sulfonamides (“sulpha” drugs).
The efficacy of long-term antibiotic prophylaxis of
recurrent UTI in children is not established.
15
Client Education:
UTI can be prevented by:
––Proper toileting (wipe from front to back)

Genitourinary System 13–11
Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010
––Drinking plenty of fluids each day
––Encouraging cranberry juice to prevent urinary
tract infections.
22,23
Cranberry juice is not effective
for the treatment of UTI
24
––Urinating when the urge is felt, not holding it in
––Emptying the bladder after intercourse (sexually
active teenagers)
PYELONEPHRITIS (SUSPECTED)
Adjuvant Therapy
––IV therapy with normal saline may be necessary for
children with pyelonephritis (before transfer)
––Run at a rate sufficient to maintain hydration
Pharmacologic Interventions
IV antibiotics may be started before transfer, on the
advice of a physician:
ampicillin 100–200 mg/kg/day, divided q6h, IV/IM
and
gentamicin (Garamycin), 5–7.5 mg/kg/day, divided
q8h, IV/IM
Monitoring and Follow-Up
––If treating as an outpatient, follow up in 24–48
hours. Review sensitivity of organisms to antibiotics
when the results of urine cultures are available
––If there is no response to oral antibiotics within
48–72 hours or if symptoms are deteriorating,
consult with a physician about changing the
antibiotic or the need for IV antibiotic therapy
Referral
––Medevac all infants under 4 months of age, and
those who appear acutely ill (at risk of sepsis),
dehydrated or who are unable to tolerate oral
medications or fluids
––Older infants and children with suspected
pyelonephritis may require medevac, depending
on their clinical condition (for example, acute
illness [sepsis], dehydration or if unable to tolerate
oral medications or fluids)
––Refer to a physician (for evaluation) any child
with culture-proven UTI who has been treated
on an outpatient basis
EMERGENCY PROBLEMS OF THE MALE GENITAL SYSTEM
TESTICULAR TORSION
25,26,27,28,29
Abnormal twisting of spermatic cord and testis, which
compromises blood supply to these structures and
results in ischemic injury and pain. Acute, severely
painful condition.
Torsion can occur at any age; however, it is most
common in adolescence, with a peak at 14 years
of age.
Testicular torsion is a medical emergency. If the blood
supply to the testis is cut off for more than about
six hours, permanent damage to the testis is likely
to occur.
PARTIAL OR INTERMITTENT
TESTICULAR TORSION
30
Torsion is not an all-or-nothing phenomenon. It can
be complete (usually twisting > 360°), incomplete
or intermittent.
Some boys and men have occasional warning pains in
a testis before developing full-blown torsion. These
episodes occur suddenly, last a few minutes, then
remit suddenly. The pain occurs if a testis twists a
little, and then returns back to its normal place on
its own.
Incomplete or partial testicular torsion is difficult to
diagnose because of its subacute presentation with
nonspecific symptoms and signs.
CAUSES
––Torsion is usually spontaneous and idiopathic
(often occurs during sleep)
––Predisposing structural (genetic) defect (for
example, inadequate fixation of testis to tunica
vaginalis, bell clapper deformity)
––Occasionally caused by minor trauma to the groin
––Strenuous physical activity
––Sexual activity or arousal
––Undescended testicle
––Testicular tumour

Genitourinary System 13–12
Pediatric Clinical Practice Guidelines for Nurses in Primary Care2010
HISTORY
––Sudden onset of severe, constant, unilateral pain
in scrotum or testicle, usually for < 12–24 hours
––Prior episodes of intermittent testicular pain may
be reported (torsion and then detorsion)
––Pain may radiate to lower abdomen
––May be described as abdominal or inguinal pain
by the embarrassed child
––Pain made worse by elevation of scrotum
––Pain not relieved by lying down
––Decreased appetite, nausea and vomiting may
be present
––Urinary frequency may uncommonly occur
––“Causes” as listed above
For intermittent torsion:
––Intermittent sharp testicular pain (resolves within
seconds to minutes)
––Long periods without symptoms
––Number of occasions it occurred
PHYSICAL FINDINGS
––Temperature usually normal
––Heart rate elevated
––Blood pressure mildly elevated (because of pain)
––Client in acute distress
––Client bent over or unable to walk
––Unilateral scrotal swelling and redness
––Testis acutely tender, may be warm
––Testis swollen and found higher up (retracted) in
the scrotal sac than expected on affected side
––Slight elevation of the testis increases or has no
effect on pain
––Testis might be lying horizontally (epididymis
not posterolateral)
––Hydrocele and scrotal skin erythema may be
present (often a later finding)
––Cremasteric reflex (elevation of testis after stroking
the upper, inner thigh on the same side) almost
always not present
For intermittent torsion, in addition to the above,
the following may also be present:
––Very mobile testes
––Bulky spermatic cord
––Normal examination
DIFFERENTIAL DIAGNOSIS
––Epididymitis
––Orchitis
––Trauma
––Hernia
––Hydrocele
––Incarcerated or strangulated inguinal hernia
––Torsion appendix testis
––Acute varicocele
––Testicular tumour
––Scrotal abscess
––Testicular infarction
––Henoch-Schönlein purpura
––Appendicitis
COMPLICATIONS
––Testicular atrophy
––Infarction of testicle
––Infection
––Abnormal spermatogenesis
––Infertility
DIAGNOSTIC TESTS
––Doppler ultrasonography helps distinguish
testicular torsion from strangulated hernia,
undescended testes or epididymitis
––If testicular torsion is present, a slight elevation of
the testis increases pain whereas in epididymitis it
relieves pain
MANAGEMENT
Goals of Treatment
––Relieve pain
––Prevent complications
Appropriate Consultation
If you suspect a testicular torsion, initiate a
consultation with a physician without delay. This is
a medical emergency; prompt diagnosis and surgical
referral is critical to a satisfactory outcome.
If intermittent torsion is suspected consult a physician.
Nonpharmacologic Interventions
––Nothing by mouth before surgery
––Bed rest
––Promote the patient’s comfort
Adjuvant Therapy
––Start intravenous (IV) therapy with normal saline
––Adjust IV rate according to age and state of
hydration

Genitourinary System 13–13
Pediatric Clinical Practice Guidelines for Nurses in Primary Care 2010
Pharmacologic Interventions
Analgesia:
morphine 0.05–0.2 mg/kg/dose SC/IM/IV
(maximum doses vary but generally should not
exceed morphine 5–10 mg)
Usual maximum dose:
31
Infants: 2 mg/dose
Note: Infants < 3 months of age are more
susceptible to respiratory depression; use with
caution and in reduced doses in this age group
Children 1–6 years: 4 mg/dose
Children 7–12 years: 8 mg/dose
Adolescents: 15 mg/dose
Monitoring and Follow-Up
If intermittent testicular torsion is suspected and
the examination was normal, follow up in 7 days
(sooner if the pain recurs) and do another complete
examination.
Referral
Medevac as soon as possible. This is a surgical
emergency.
For those with suspected intermittent testicular
torsion, refer to a physician as a urology referral is
often warranted.
SOURCES
Internet addresses are valid as of February 2012.
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END NOTES
1 Hockenberry MJ, Wilson D. Wong’s nursing care of
infants and children. 8th ed. Mosby Elsevier; 2007.
p. 1233.
2 Shaikh N, Hoberman A. (September 2010). Clinical
features and diagnosis of urinary tract infections
in children. UpToDate Online 18.3. Available by
subscription: www.uptodate.com
3 Drutz JE. (January 2010). The pediatric physical
examination: Chest and abdomen. UpToDate Online
18.1. Available by subscription: www.uptodate.com
4 Drutz JE. (January 2010). The pediatric physical
examination: The perineum. UpToDate Online 18.1.
Available by subscription: www.uptodate.com

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5 Hockenberry MJ, Wilson D. Wong’s nursing care of
infants and children. 8th ed. St. Louis, MO: Mosby
Elsevier; 2007. p. 1242-48.
6 Geetha D. (2010). Glomerulonephritis,
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medscape.com/article/240337-overview
7 Nurses Quick Check. 2nd ed. Hydrocele. Lippincott
and Wilkins; 2009. p. 382.
8 Brenner JS, Ojo A. (January 2010). Causes of
painless scrotal swelling in children and adolescents.
UpToDate Online 18.1. Available by subscription:
www.uptodate.com
9 Burns C, Dunn A, Brady M, Barber Starr N, Blosser
C. Pediatric primary care. 4th ed. St. Louis, MO:
Saunders; 2009. p. 924-927.
10 Public Health Agency of Canada. (January 2010).
Canadian guidelines on sexually transmitted
infections. Bacterial vaginosis: Management and
treatment. p. 7. Available at: http://www.phac-aspc.
gc.ca/std-mts/sti-its/pdf/sti-its-eng.pdf
11 Nepple K, Cooper C. (January 2010). Etiology and
clinical features of voiding dysfunction in children.
UpToDate Online 18.1. Available by subscription:
www.uptodate.com
12 National Institute of Diabetes and Digestive and
Kidney Diseases (NIDDK). (2006). Urinary
incontinence in children. Available at: http://kidney.
niddk.nih.gov/kudiseases/pubs/uichildren/
13 Shaikh N, Hoberman A. (September 2010).
Epidemiology and risk factors for urinary tract
infections in children. UpToDate Online 18.3.
Available by subscription: www.uptodate.com
14 Hockenberry MJ, Wilson D. Wong’s nursing care of
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15 Williams G, Wei L, Lee A, Craig JC. Long-
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16 O’Donovan DJ. (January 2010). Urinary tract
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Available by subscription: www.uptodate.com
17 Shaikh N, Hoberman A. (January 2010). Clinical
features and diagnosis of urinary tract infections
in children. UpToDate Online 18.1. Available by
subscription: www.uptodate.com
18 Anti-infective Review Panel. Anti-infective
guidelines for community-acquired infections.
Toronto, ON: MUMS Guideline Clearing House;
2010. p. 70.
19 Palazzi DL, Campbell JR. (2010). Acute cystitis
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Available by subscription: www.uptodate.com
20 Dulczak S, Kirk J. (2005). Evaluation, diagnosis,
& management of UTIs in children: Radiologic
diagnosis of UTI.
21 Uphold C, Graham MV. Clinical guidelines in child
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22 Jepson RG, Craig JC. (2009). Cranberries for
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frame.html
23 Nurses Quick Check. 2nd ed. Urinary tract infection.
Lippincott and Wilkins; 2009. p. 859.
24 Jepson RG, Mihaljevic L, Craig JC. Cranberries
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CD001322. Retrieved August 2010. Available at:
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CD001321.pub4/abstract
25 Nurses Quick Check. 2nd ed. Testicular torsion.
Lippincott and Wilkins; 2009. p. 808.
26 Burns C, Dunn A, Brady M, Barber Starr N,
Blosser C. Pediatric primary care. 4th ed. St. Louis,
MO: Saunders; 2009. p. 901-02.
27 Brenner JS, Ojo A. (2010, September). Causes
of scrotal pain in children and adolescents.
UpToDate Online. Available by subscription:
www.uptodate.com
28 Eyre RC. (2010, September). Evaluation of the acute
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29 Rupp TJ. (2010, September 27). Testicular torsion.
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30 Dogra V, Bhatt S, Rubens D. Sonographic
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31 Morphine sulfate: Pediatric drug information.
(September 2010). UpToDate Online 18.3.
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