Genitourinary Disorders

A variety of vulvovaginal, pelvic, and genital complaints are common presentations in the pediatric urgent care setting, including those due to infection, congenital abnormality, and trauma. In this section, we review management of the following genitourinary complaints:

• Vaginitis

• Urethral Prolapse

• Straddle Injuries

• Neonatal Uterine Bleeding

• Phimosis

• Paraphimosis

• Balanitis/Balanoposthitis

• Scrotal Swelling

Other adolescent genitourinary issues and related topics are covered in the following rotation guides:

• Abdominopelvic Emergencies (Pediatric Emergency Medicine)

  • urinary tract infection

  • testicular torsion

  • gynecologic emergencies

• Sexual Abuse (Child Abuse and Neglect)

• Sex and Sexuality (Adolescent Care)

Vaginitis

Inflammation of the vagina causes symptoms of vaginal itching, pain, burning, and discharge. This section reviews the presentation and management of vulvovaginitis in prepubertal and postpubertal girls separately.

Prepubertal Girls

Risk factors: Prepubertal girls are at risk of developing vulvovaginitis because of a number of potential factors:

• increased risk of bacterial infections due to underdeveloped labia minora and minimal adipose tissue in labia majora

• fewer lactobacilli and potential for increased pathogens due to the alkaline pH of the unestrogenized vagina

• hygiene issues resulting from poor wiping and handwashing skills and frequent nose-picking and -scratching

• tight-fitting clothing

• irritation from contact with harsh soaps, bubble baths, and laundry detergent

• recent enteritis, respiratory infections, or antibiotic usage that precipitates infection

Etiology:

• Irritation and poor hygiene are the two most common causes of vaginitis in this age group. Therefore, treatment is generally supportive and includes sitz baths, counseling to wear loose-fitting clothing, and teaching appropriate hygiene skills. Laboratory testing is generally not required unless vaginal discharge is present or infectious etiology is suspected.

• Group A streptococcal infection is a common bacterial cause of vaginitis in young girls and presents with erythema and inflammation of the vaginal area.

• Pinworms, which classically present with anal itching, can also be associated with vaginal irritation in females as a result of excoriation.

• Vaginal foreign body (typically bits of toilet paper or small toys) can present with a foul-smelling vaginal discharge accompanied by bleeding, lower abdominal pain, or dysuria. Foreign bodies can sometimes be removed with irrigation but may require an exam under anesthesia for identification and removal.

• Sexually transmitted infections (STIs) often present with vaginal discharge and should prompt possible evaluation for sexual abuse in prepubertal girls (see STIs in the Adolescent Care rotation guide).

Postpubertal Adolescents

Risk factors:

• higher estrogen levels

• lower vaginal pH

• increased risk for STIs

History should include the following information:

• description of the vaginal discharge

• dates of last menstrual period

• usage of tampons/pads

• medication usage

• self-treatment

• sexual history (see The CDC Guide to Taking a Sexual History and Sex and Sexuality in the Adolescent Care rotation guide)

Etiology

• Noninfectious vaginitis in adolescents is often caused by:

  • retained foreign body (e.g., tampon or condom)

  • perfumed soaps or bubble bath

  • douching or vaginal sprays

• Infectious vaginitis in adolescents is most often caused by bacterial vaginosis, trichomoniasis, and yeast:

  • bacterial vaginosis

    • symptoms: vaginal itching, fishy odor, thin vaginal discharge

    • diagnosis: presence of three of four Amsel criteria

      • gray/white discharge

      • >20% clue cells on wet mount microscopy

      • positive whiff test with potassium hydroxide (KOH) added to wet mount (KOH prep test)

      • vaginal fluid pH >4.5

    • trichomoniasis

      • symptoms: purulent, malodorous, frothy vaginal discharge; may also have dysuria, pruritus, or abdominal pain

      • diagnosis: presence of motile trichomonads on wet mount or positive nucleic acid amplification test (NAAT)

    • yeast

      • symptoms: pruritus, vulvar burning, dysuria

      • diagnosis: pseudohyphae, hyphae, or budding yeast on KOH wet prep (addition of 10% potassium hydroxide) or culture-growing yeast

Urethral Prolapse

Urethral prolapse is a relatively rare condition in prepubertal girls and can be due to cough, trauma, or constipation. Symptoms of urethral prolapse include vaginal bleeding (most common), dysuria, and visualization of a perineal mass. On examination, this mass will appear “doughnut-like,” with a central dimple at the distal urethra, as illustrated in the following image.

(Source: Urethral Prolapse. AboutKidsHealth.ca, The Hospital for Sick Children, Toronto, Canada ©2019.)

Management: Treatment of urethral prolapse is typically with topical estrogen cream twice daily for 2 weeks. Sitz baths may also be helpful. Although rare, any concerns for malignancy, such as sarcoma botryoides, urinary obstruction, or necrosis, should prompt immediate specialty consultation.

Straddle Injuries

A straddle injury is trauma to the perineal area due to the force generated by the weight of the patient’s body. Such injuries often result from falling on a bicycle bar, a barlike apparatus in the playground, the side of a bathtub, furniture, or the edge of a pool. Girls generally present with bleeding, and boys are more likely to present with pain to the genitourinary region.

Evaluation should include examination for a penetrating injury. Injury to the hymen or bleeding from the vaginal opening should raise concern for a deeper injury to the pelvic region. Consider appropriate pain control, anxiolysis, and distraction (e.g., utilization of child life specialists) during the exam.

Management: Treatment consists of pain management, cleaning the area, and hemostasis, which may require gentle pressure or sutures. Most straddle injuries heal quickly and can be treated with supportive care. Specialty consultation should be considered if sedation is required for a complete exam, for severe injuries requiring laceration repair, and if the child is unable to urinate.

Neonatal Uterine Bleeding

Neonatal uterine bleeding, or newborn withdrawal bleeding, may occur in a female infant’s first 10 days of life due to the sudden decrease in maternal estrogens after birth. The bloody discharge can last a few days and requires no treatment.

Phimosis

Phimosis is a nonretractile prepuce or foreskin that can be physiologic or pathologic. Only a small number of newborns have fully retractable foreskin at birth. Phimosis decreases with age. Fifty percent of uncircumcised boys have retractile foreskins by age 1 year, 90% by age 3 years, and 99% by adolescence.

• Physiologic phimosis is due to the normal adhesions between the foreskin and glans.

• Pathologic phimosis is foreskin that is nonretractable due to development of abnormal adhesions and scarring of the prepuce. Phimosis is considered pathologic if the foreskin is not retractable by the end of puberty or if a previously retractable foreskin becomes nonretractable.

• Physiologic phimosis can be differentiated from pathologic phimosis by the lack of a constricting ring and lack of scarring.

Management: Parents should be instructed not to forcibly retract the foreskin because scarring can worsen the condition.

• Physiologic phimosis does not require treatment. Most infants have foreskin that is nonretractable. As the foreskin loosens, caregivers can gently retract the foreskin for cleaning during bathing or diaper changes or teach the child to gently retract as much as they are able during toilet training (depending on the age at which the foreskin separates). Older boys should be taught to retract the foreskin regularly, cleansing with water and returning it to the normal position.

• Pathologic phimosis is treated medically with topical glucocorticoid creams twice a day for 4−8 weeks, and surgically with circumcision if needed or desired. Of note, an immediate surgical evaluation is necessary if the patient is unable to pass urine. Outpatient consultation with surgery for circumcision may be indicated, depending on severity and family preference (depending on age).

Paraphimosis

Paraphimosis describes a condition in uncircumcised boys in which the foreskin is retracted and cannot be reduced due to edema of the distal penis. Paraphimosis is a surgical emergency requiring immediate intervention to prevent necrosis.

Evaluation: Patients with paraphimosis present with painful swelling of the penis and may also have dysuria or urinary obstruction. The area will be erythematous and tender, with a constricting band proximal to the head of the penis, and eventually will become blue or black due to ischemia of the glans. Evaluation should ensure that foreign bodies (e.g., hair, clothing, or rubber bands) are not constricting the penis.

(Source: N Engl J Med 2013.)

Management: Paraphimosis is treated by reduction of the foreskin and requires pain control. Manual reduction should be attempted after swelling is reduced by placing ice or compression bandages on the glans. Urology should be emergently consulted; if manual reduction fails, a dorsal slit procedure can be utilized. See a video demonstration of reduction of paraphimosis.

Balanitis/Balanoposthitis

Balanitis is inflammation of the glans penis and can affect both circumcised and uncircumcised males. Balanoposthitis is inflammation of the glans penis and foreskin (prepuce) in uncircumcised males.

The foreskin naturally covers the glans penis and functions to protect the glans and external urethra. Adhesions beneath the foreskin, physiologically present at birth, gradually separate over time and allow retraction of the foreskin. The glans and prepuce can become inflamed in uncircumcised males due to infection, irritation, or trauma. Infections can be due to a fungal or bacterial cause. Irritation is typically caused by poor hygiene, tight-fitting clothing, or excessive cleaning with a harsh detergent. Forceful retraction of the foreskin and zipper injuries may cause tearing of the skin, causing traumatic balanoposthitis. Rarely, balanitis xerotica obliterans, or lichen sclerosus of the male genitalia, can also cause irritation of the foreskin, urethral meatus, or both.

Evaluation: Clinical features on physical examination are erythema and edema of the glans, the foreskin, or both, and may include exudate or foul odor. Patients with balanoposthitis often have phimosis and should be carefully evaluated for ability to retract the foreskin.

(Source: Balanitis and Balanoposthitis. Abdominal Key 2017.)

Diagnosis: Balanitis and balanoposthitis are clinical diagnoses and do not require laboratory testing if there are no signs of induration or urethral discharge. However, if group A streptococcal infection or STI is suspected, the patient should undergo laboratory evaluation with a culture. When testing for group A streptococcus, the sample should be obtained from the pharynx. If the pharyngeal swab is negative, culture should also be obtained from the preputial drainage.

Treatment:

• Treatment is dependent on the cause of the inflammation, but most patients can be appropriately treated with a topical antifungal or antibiotic ointment (avoid use of neomycin-containing ointments on the penis due to potential for chemical irritation).

• Systemic antibiotics may be indicated if group A streptococcal infection, staphylococcal infection, or STI are suspected.

• An irritant or contact balanoposthitis may be treated with mild topical glucocorticoid twice daily for one week. However, prolonged usage is not recommended.

• All patients should be given instructions on how to maintain hygiene and prevent recurrent episodes, including instructions to gently clean between the foreskin and glans and irrigate the area with clean water. Soap should not be used under the foreskin and forceful retraction should be avoided.

Scrotal Swelling

Swelling of the scrotum may be due to various causes (see table below). Testicular torsion is the most significant cause and a true surgical emergency (see the Pediatric Emergency Medicine rotation guide for an overview of testicular torsion). History should include information on onset of pain, swelling, redness. and discharge. Sexual history should also be obtained in an adolescent.