Although few children are severely ill when evaluated in the pediatric office, developing the skills to recognize an infant or child who requires hospitalization is critical. Some children will require treatment in an emergency department or direct admission to an inpatient facility, whereas other children can be managed as outpatients. Determining when an infant requires an inpatient admission is particularly important because the metabolic reserve is less abundant in the newborn. Patients with hemodynamic instability must be emergently addressed. This article outlines the most common urgent and emergent pediatric urological conditions with the goal to direct initial evaluation and treatment.
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Children with acute abdominal pain should be evaluated immediately. In addition to a thorough abdominal examination to rule out surgical disease, these children should be evaluated for urinary tract infection, constipation, and spermatic cord torsion.
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A child with acute scrotal pain must be presumed to have spermatic cord torsion regardless of age until proven otherwise; however, in some cases, an accurate evaluation may prevent an unnecessary surgical exploration.
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The differential diagnosis of a vaginal mass includes benign periurethral cysts, skin tags, urethral prolapse, imperforate hymen, prolapsed ureterocele, or rarely, malignancies such as a rhabdomyosarcoma.
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Blunt force renal trauma requires immediate evaluation but does not necessarily require operative intervention. The conservative treatment of high-grade blunt renal injuries has been successfully described in children. Children with high-grade injuries at risk for failure of conservative management include those with vascular avulsion or extensive urinary extravasation, especially in the setting of ureteropelvic junction disruptions.
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Infants with ambiguous genitalia require immediate evaluation because congenital adrenal hyperplasia may result in salt wasting, which can be life-threatening.
The initial assessment must accurately determine the degree of acuity and the level of care required. Although few children are severely ill when evaluated in the pediatric office, developing the skills to recognize an infant or child who requires hospitalization is critical. Some children will require treatment in an emergency department or direct admission to an inpatient facility, whereas other children can be managed as outpatients. Determining when an infant requires an inpatient admission is particularly important because the metabolic reserve is less abundant in the newborn. Patients with hemodynamic instability must be emergently addressed. This article outlines the most common urgent and emergent pediatric urological conditions with the goal to direct initial evaluation and treatment.
Acute abdominal conditions
Children with acute abdominal pain should be evaluated immediately. An accurate history of the nature of the pain may be the best indicator of the source of the pain. Details about the character of the pain, including timing, acuity of onset, radiation, and migration are important and should, if possible, be elicited directly from the child. Associated loss of appetite, nausea, vomiting, or a change in bowel pattern may help to distinguish gastrointestinal from genitourinary sources. Causes of abdominal pain in children vary widely and are often unique to the pediatric population. Pyelonephritis, renal colic, or cystitis are potential etiologies within the differential diagnosis. Renal colic can result from obstructing nephrolithiasis, ureteropelvic junction obstruction, ureterovesical junction obstruction, or clot obstruction. Nonurological intra-abdominal etiologies in children include gastroenteritis, constipation, mesenteric adenitis, pyloric stenosis, midgut volvulus, appendicitis, and intussuception. Nonabdominal sources, such as sickle cell crisis, streptococcal pharyngitis, or pneumonia, should also be considered. In addition to a thorough abdominal examination designed to rule out surgical abdominal disease, these children should be evaluated for urinary tract infection (UTI), constipation, and spermatic cord torsion. Usually an acute abdominal series is ordered, which will demonstrate considerable amounts of stool throughout the colon if constipation is the cause. Occasionally, some children with spermatic cord torsion complain of abdominal pain and have minimal scrotal complaints. Therefore, a scrotal examination must always accompany an abdominal examination. Most abdominal masses originate in genitourinary organs and should be evaluated immediately. In neonates, transillumination of the abdomen may assist in distinguishing between solid and cystic lesions. The most common malignant abdominal tumor in infants is neuroblastoma, followed by Wilms tumor. Children with neuroblastoma typically relate a history of more constitutional symptoms than children with Wilms tumor.
If an abdominal mass is suspected, an abdominal ultrasound evaluation should be ordered. If the mass is solid, computed tomography (CT) is almost always required. Renal pathology is the source of up to two-thirds of neonatal abdominal masses. Cystic abdominal masses include hydronephrosis, multicystic dysplastic kidneys, adrenal hemorrhage, hydrometrocolpos, intestinal duplication, and choledochal ovarian omental or pancreatic cysts. Solid masses include neuroblastoma, congenital mesoblastic nephroma, hepatoblastoma, and teratoma. A solid flank mass may be caused by renal venous thrombosis, which becomes apparent with signs of hematuria, hypertension, and thrombocytopenia. Renal venous thrombosis in infants is associated with polycythemia, dehydration, diabetic mothers, asphyxia, sepsis, and coagulopathies, such as antithrombin-3 or protein C deficiencies.
Nephrolithiasis
The incidence of nephrolithiasis in children is increasing in the United States: 1000 to 7500 hospital admissions in the United States result from pediatric nephrolithiasis. Nephrolithiasis can be associated with significant metabolic disturbances and underlying medical conditions. The presence of nephrolithiasis does not represent an emergent situation but does require urology and nephrology evaluation. Certain clinical signs and patient characteristics must be assessed to determine the acuity of the patient. Children with renal calculi often present with renal colic. Patients often complain of abdominal pain, flank pain, lower quadrant pain, and or scrotal pain. In young children, abdominal symptoms can often be vague and more difficult to localize. Although nephrolithiasis is more common in adolescents, 20% of pediatric nephrolithiasis occurs in newborns and infants. Children with renal ectopia, such as pelvic kidneys, also present with atypical symptoms. Nausea, emesis, and gross hematuria often accompany the abdominal pain.
Children with obstruction of a solitary system, urinary tract infection, renal insufficiency, immunosuppression, uncontrollable pain, and/or the inability to tolerate oral intake should be evaluated emergently. These children should be assessed in the emergency department with a complete blood count, metabolic panel, urine analysis, urine culture, and abdominal imaging. A renal and bladder ultrasound often provides adequate diagnostic information, but a CT scan of the abdomen and pelvis is warranted in some cases. The sensitivity of ultrasound is significantly lower than CT imaging but the risk of malignancy associated with irradiation must be considered. An infected obstructing ureteral calculus can result in urosepsis and death; therefore, these children should be stabilized, administered broad-spectrum intravenous (IV) antibiotics, and the obstructed renal unit decompressed. In an unstable patient, percutaneous nephrostomy tube placement is the safest and most efficient management.
Nephrolithiasis
The incidence of nephrolithiasis in children is increasing in the United States: 1000 to 7500 hospital admissions in the United States result from pediatric nephrolithiasis. Nephrolithiasis can be associated with significant metabolic disturbances and underlying medical conditions. The presence of nephrolithiasis does not represent an emergent situation but does require urology and nephrology evaluation. Certain clinical signs and patient characteristics must be assessed to determine the acuity of the patient. Children with renal calculi often present with renal colic. Patients often complain of abdominal pain, flank pain, lower quadrant pain, and or scrotal pain. In young children, abdominal symptoms can often be vague and more difficult to localize. Although nephrolithiasis is more common in adolescents, 20% of pediatric nephrolithiasis occurs in newborns and infants. Children with renal ectopia, such as pelvic kidneys, also present with atypical symptoms. Nausea, emesis, and gross hematuria often accompany the abdominal pain.
Children with obstruction of a solitary system, urinary tract infection, renal insufficiency, immunosuppression, uncontrollable pain, and/or the inability to tolerate oral intake should be evaluated emergently. These children should be assessed in the emergency department with a complete blood count, metabolic panel, urine analysis, urine culture, and abdominal imaging. A renal and bladder ultrasound often provides adequate diagnostic information, but a CT scan of the abdomen and pelvis is warranted in some cases. The sensitivity of ultrasound is significantly lower than CT imaging but the risk of malignancy associated with irradiation must be considered. An infected obstructing ureteral calculus can result in urosepsis and death; therefore, these children should be stabilized, administered broad-spectrum intravenous (IV) antibiotics, and the obstructed renal unit decompressed. In an unstable patient, percutaneous nephrostomy tube placement is the safest and most efficient management.
Acute scrotal conditions
Testicular Torsion
The annual incidence of testicular torsion in boys younger than 18 years is 3.8 per 100,000. A child with acute scrotal pain must be presumed to have spermatic cord torsion regardless of age until proven otherwise; however, in some cases, an accurate evaluation may save the child an unnecessary surgical exploration. The differential diagnosis of the acute scrotum includes testicular torsion, torsion of the appendix testis or epididymis, epididymitis/orchitis, hernia/hydrocele, trauma, sexual abuse, tumor, idiopathic scrotal edema, dermatitis, cellulitis, and vasculitis, such as Henoch-Schonlein purpura. Gradual onset of the pain is more consistent with epididymitis, whereas abrupt pain suggests spermatic cord torsion or torsion of one of the testicular appendices. The classical presentation of testicular torsion is the sudden onset of severe, unilateral pain that is often associated with nausea and emesis. Pain is present with palpation and at rest. A history of similar intermittent episodes may suggest intermittent testicular torsion.
The acute scrotum should be examined carefully to determine the true etiology. Observation of the child’s general appearance and level of distress should be recognized. Scrotal erythema, edema, or ecchymoses should be readily identifiable. To begin the scrotal examination, the inguinal canal should be inspected on each side for signs of asymmetry or mass. The inguinal canal is then palpated to identify a fullness or mass suggestive of a hernia or hydrocele of the spermatic cord. Testicular torsion may present with varied clinical findings, but the involved testis often demonstrates signs such as higher riding in the hemiscrotum, a transverse orientation, an anterior epididymis, absent cremasteric reflex, and tenderness of the testis and epididymis. Associated scrotal wall swelling or erythema is suggestive of spermatic cord torsion if presentation is delayed. The absence of edema or erythema or the presence of a cremasteric reflex does not rule out the possibility of acute testicular torsion, especially if the onset of pain was recent.
In contrast, torsion of the appendix testis or epididymis often results in localized tenderness at the superior pole of the testis or caput epididymis and is often associated with a reactive hydrocele. Additionally, in boys with thin scrotal skin, the “blue dot” sign can be seen reflective of a necrotic appendix. Epididymitis classically has a gradual onset and is not associated with nausea or emesis but can have similar clinical signs, including a firm, tender, enlarged testis with an erythematous and edematous scrotum.
The normal newborn scrotum is relatively large. Its size may be increased with the trauma of breech delivery or by a newborn hydrocele. A hydrocele can be distinguished from hernia by palpation and transillumination, as well as from the absence of a mass in the inguinal canal. In the absence of volume changes within the hydrocele, the processus vaginalis is usually not patent and the newborn hydrocele resolves by 1 year of age without surgery. Neonatal extravaginal testicular torsion can also occur prenatally resulting in a firm, enlarged, nontender mass in the hemiscrotum that is usually associated with dark discoloration of the overlying skin. A normal scrotal examination at birth and subsequent development of erythematous, tender, edematous hemiscrotum suggests postnatal extravaginal testicular torsion and should be addressed immediately with surgical intervention if the neonate is clinically stable.
Traditionally significant ischemic damage is believed to occur after 4 to 8 hours. Therefore, testicular torsion represents a true surgical emergency. If there is a concern for testicular torsion, the patient should be sent to the emergency department for immediate evaluation. Patients presenting after 8 hours are usually still explored because the viability of the testis is difficult to predict. Despite emergent scrotal exploration and detorsion, 32% of testes are nonviable and result in orchiectomy based on a review of the Pediatric Health Information System database. Intraoperatively, the ipsilateral hemiscrotum will be explored and the testis will be identified and the spermatic cord torsion is released. At that time, the affected testis is observed for return of blood flow and wrapped in moist gauze. The contralateral hemiscrotum is then explored and a contralateral scrotal orchidopexy or septopexy is performed. The objective of exploring the contralateral testis and performing a septopexy is to prevent metachronous testicular torsion. If the ipsilateral testis appears healthy, a septopexy is performed. If the affected testis is unable to be salvaged, an orchiectomy is performed.
Hernia/Hydrocele
Infants and children with an inguinal hernia or a hydrocele that changes in volume should be seen within 24 hours and sooner if there is history of inguinal or scrotal pain. Most of these children will need surgical intervention, but a few will require emergent surgery. If there is a history of scrotal or inguinal pain, the child’s parents should be taught to recognize the signs of an incarcerated inguinal hernia and instructed to go to the emergency department if symptoms occur before the planned surgical correction. Infants with asymptomatic hydrocele rarely require surgery initially. In most cases, the hydrocele will resolve in the first year of life. An exception should be made if the hydrocele is particularly large or palpable in the inguinal region. A large hydrocele with a palpable inguinal component or one that is enlarging may indicate the presence of an abdominoscrotal hydrocele. These do not spontaneously resolve and usually enlarge. These should be corrected, usually at 6 to 12 months through an initial scrotal incision that will decompress the hydrocele.
Testicular Masses
Testicular masses should be evaluated immediately. Prepubertal testicular and paratesticular tumors should be considered in the differential diagnosis of a scrotal mass. Although much less common than epididymal cysts or spermatoceles, a complaint of a painless testicular or paratesticular mass should be addressed urgently. A physical examination and scrotal ultrasound should determine if the mass is concerning for neoplasia. Scrotal masses can be transilluminated to determine if the component is primarily fluid, such as a tense hydrocele or solid, such as a testicular tumor. If a firm intratesticular mass is palpated, a thorough examination of the lymph nodes should be performed to evaluate for lymphoma, leukemia, or metastatic disease. Patients with a nontender testicular mass and signs of precocious puberty should be evaluated for a Leydig cell tumor or, less commonly, a Sertoli cell tumor. Epididymal cysts and spermatoceles can present as extratesticular masses but are characteristically smooth, round, and located within the epididymis. A scrotal ultrasound can further differentiate these physical examination findings. Boys with a complaints of a scrotal mass should be assessed by a pediatric urologist urgently due to the rapid growth and malignant potential of many lesions. If the ultrasound or examination are suggestive of a intratesticular or paratesticular mass, tumor markers including beta human chorionic gonadotropin, alpha fetoprotein, and lactate dehydrogenase must be obtained. Additionally, in most instances a CT scan of the abdomen and pelvis with oral and IV contrast is indicated.
In a contemporary series from a tertiary center, the most common prepubertal testis tumor was a teratoma followed by rhabdomyosarcoma, epidermoid cyst, yolk sac tumor, and germ cell tumor, respectively. This histologic distribution was corroborated by a multicenter review including 4 tertiary pediatric hospitals demonstrating that 74% of tumors were benign with 48% teratoma. Testicular tumors occur in the newborn and in early childhood as well as after adolescence. The peak incidence of testicular tumors in young children and infants occurs at age 2. In this population, yolk sac tumors are most common and approximately 75% of tumors are malignant. Tumors of nontesticular origin, such as leukemia and lymphoma, must also be considered in the pediatric population.
Varicocele
Varicoceles are uncommon in prepubertal boys and increase in incidence to around 15% by 15 years of age. A physical examination and scrotal ultrasound confirm the diagnosis. From the 3-dimensional measurements on ultrasound, the relative testicular volumes may be calculated and used to guide further treatment. Varicoceles are 90% left-sided and 10% right-sided. Although a left-sided varicocele is not a urological emergency, a right-sided varicocele in the absence of a left-sided varicocele should prompt an evaluation for a retroperitoneal process. If only the right side is involved, there exists a possibility that a retroperitoneal tumor is present and compressing the vein.
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