Pediatric GU and Endo Emergencies

S. McPhersonDec 11, 2003

What are some causes of painless scrotal/testicular selling?

Hydrocele Testicular tumor HSP Varicocele Inguinal hernia Idiopathic scrotal edema

How do you diagnose a hyrdocele?

Enlarged scrotum Fluid may transilluminate Not painful No palpable mass Usually right sided

May need an ultrasound to to differentiate cause of hydrocele

Arrange outpatient follow-up

How can you differentiate btn a hydrocele and an inguinal hernia?

History of straining causes swelling Hernia may have bowel sounds on

auscultation Hernias can be felt at the internal inguinal

ring and hydroceles cannot

How do varicoceles present? Usually > 10 yrs old Usually painless unilateral selling Worse when standing “bag of worms”

What might lead you to believe there is something sinister causing the varicocele? Right sided Acute onset of left sided

When might they need surgical correction? Pain Bilateral Decreased spermatogenesis Testicular hypotrophy

What are some painful causes of scrotal/testicular swelling?

Torsion Epididymitis Torsion of the testicular appendage Incarcerated hernia Testicular rupture Hemorrage into testicular tumor

How does testicular torsion present?

Acute scrotal pain Scrotal swelling Negative cremasteric reflex (may be

present if early or incomplete torsion) Abnormal position of testicle (retracted

may have transverse lie) Swollen testicle Nausea, vomiting, fever, abdo pain

What should you do if you strongly suspect a torsion? Surgical consult ASAP If any appreciable delay can try manual

reduction How do you manually reduce a

torsion? Provide adequate analgesia/sedation Rotate testis from medial to lateral until

completely untwisted

What is the role of ultrasound?

Used in early and equivicle cases to help confirm the diagnosis

If strongly suspicious of torsion after Hx/Px you shouldn’t delay surgical consultation to get an U/S

Sensitivity 82-86%, specificity ~ 100% PEMR Mar 2003

Why is time so important in the treatment of torsion?

Success rates post detorsion < 4 hr 96% 4-8 hr 93% 8-12 hr 80% 12-24 hr 40% > 24 hrs < 10%

Ann Surg. 1984;200:664-73

How can you differentiate testicular torsion from torsion of the appendage?

Age for appendage torsion usually 7-12 Early pain may be localized to upper pole with

remainder of testis nontender Early may see blue dot sign U/S shows normal or increased blood flow to

testis

What is the treatment for appendage torsion?

Analgesia Anti-inflammatories Rest Should resolve in 2-12 days

How do you make the diagnosis of epididymitis?

Rarely seen in prepubertal boys Onset of swelling and pain usually more gradual

than with torsion Most will have cremasteric reflex Early on can often localize pain to epididymis May have + Prehn’s sign (relief of pain with

elevation of scrotum) May have dysuria, frequency, fever, pyruria U/S increased blood flow to testis

How do you manage epididymitis?

Urinalysis, test for chlamydia and gonorrhoeae Analgesia, sitz baths, elevation of scrotum

Antibiotics: Nonsexually acquired: TMP/SMX x 10d Sexually acquired: 125 mg Ceftriaxone IM and Doxy 100 bid for

10 days

All prepubertal and epididymitis with a UTI should be investigated for structural abnormality with U/S and VCUG

What are causes of penile pain and or swelling?

Balanitis/balanoposthitis Paraphimosis Phimosis Penile tourniquet syndrome Insect bite Generalized edematous states

What is balanitis and how do you treat it?

Inflammation of the glans +/- foreskin Causes:

Infection Chemical irritation Trauma Contact dermatitis

Treatment: Adequate hygiene Sitz baths 1st generation cephalosporin for 5-7 d if cellulitis

What is paraphimosis? Inability to reduce the foreskin over the glans Can cause a tourniquet like effect May get infected

How can you fix it?1. Put ice water in a glove over the glans for 5

min then circumferential compression of penis from glans to base, hopefully foreskin will slip over

2. Manual reduction “turn sock inside out”3. Circumcision or dorsal slit if all else fails

How do UTI’s present in kids?

Neonates: poor feeding, vomiting, jaundice, irritability, lethargy, sepsis

Infant: fever, vomiting, diarrhea, symptoms as above

Children: fever, dysuria, abdo pain, hematuria, cloudy foul urine, incontinence, eneuresis, frequency, hesitancy

What is the incidence of UTI’s in febrile kids?

Neonates: 4.6% < 1yrs 5.3%

2.5% boys 8.8% girls

Recurrence rate 18-26% in the first year (recurrence decreases with age)

Emerg Med Clin Aug 2001

When should you work up a UTI?

All neonates with fever, and signs/symptoms listed earlier

Febrile girls < 2 yrs without another obvious source

Febrile boys < 6 month without an obvious source

Children with signs and symptoms suggesting a UTI

How should you get the urine specimen?

< 2-3 month: cath or suprapubic aspiration < 2-3 year: cath or suprapubic aspiration

is best. Can do a bag specimen but if at all positive on microscopy will need a cath or aspirate to confrim

> 2-3 yr: clean catch mid-streamEmerg Med clinic Aug 2001

How do you do a suprapubic aspiration?

Local anesthesia Perpendicularly insert 21 or 25 gauge

needle one finger breadth above the pubic symphysis

Aspirate out urine

How good is the urinalysis?

How do you treat a UTI?

< 3 months: admit with iv amp and gent > 3 months and febrile:

Conservative: outpatient iv antibiotics (2-3rd gen cephalosporin) until afebrile

Less conservative: one dose parenteral antibiotics (gent or ceftriaxone) followed by 10-14 days of oral

10-14 days oral Uncomplicated cystitis

7-14 days oral (TMP/SMX, Cephalexin, amoxicillin, cefixime, nitrofurantoin); 7d if > 2yrs old

What follow-up should you arrange?

If febrile should be seen in 24-48 hr

Arrange for pediatrician or family MD to work up for structural abnormality All 2m-2y with first UTI should have VCUG and U/S

Pediatrics.1999;103:834-853 Some advocate all boys with first UTI regardless of

age and girls < 5yrs

How do children in DKA present?

Initial presentation of 20-40% of new IDDM May have Hx of polayuria/polydipsia before

decompensation Nausea, vomiting, abdo pain, increased

listlessness , altered LOC, Coma (< 10%) Signs of dehydration, Kussmaul resps, ketone

smell of breath, abdo tenderness Elevated serum glucose, ketones in urine, pH <

7.3, HCO3< 15

How do you manage a child in DKA?

Fluids: 20ml/kg NS over first hour (bolus if in shock) Replace rest of fluid deficit over 24-48 hr Assume dehydration is 10% of body weight

Lytes: Watch K+, pt will be deplete even if initial labs normal Replce K+ after initial fluid rescussitaiton and pt has urinated and follow

lytes q4h

Insulin: Infusion 0.1U/kg/hr, don’t bolus Follow chemstrip q1h

What about HCO3?

Not recommended in DKA May increase risk of cerebral edema

How is cerebral edema diagnosed and what is the risk?

Occurs in ~ 1% of all DKA Responsible for 50-60% of diabetes related

death Mortality rate up to 90% Onset within 24 hr of treatment

Irritability, disoriented, confused, lethargy, focal neuro findings, fixed dilated pupils, resp arrest

CT evidence or cerebral edema

What are the risk factors for cerebral edema?

NEJM. 2001;344(4):264-69 61 pt with cerebral edema compared to random controls and

matched controls RISKS:

High initial BUN (RR 1.8 for every increase in 9mg/dL) Low initial PCO2 (RR2.7 for every decrease in 7.8 mmHg) Treatment with HCO3 (RR4.2)

J of Pediatrics. 2002;141:793-7 Used the same 61 kids above RISKS:

High initial BUN Greater neurologic depression at time of dx Intubation with hyperventillation

What is CAH?

Inborn errors of steroid synthesis How does it present?

Acute salt-wasting crisis 2-5 weeks after birth Poor feeding, poor weight gain, lethargy, irritability,

vomiting, potentially shocky and acidotic Ambiguous genitalia

What should you do if you suspect an acute salt wasting crisis?

Get lytes, glucose and cap gas Usually have high K+ and low Na+ May have normal or low glucose

Blood for adrenal steroid profile (before hydrocortisone given)

Fluid bolus 20ml/kg NS Correct hypoglycemia 2mg/kg hydrocortisone

Hypoglycemia….what should you know

How to treat 0.5-1g/kg iv bolus Neonates D10 Children D25 Adolescent D50 Then 6-8mg/kg/min

Think about what caused it

Causes of hypoglycemia Neonatal: infant of diabetic mother, prematurity,

hypothermia, systemic illness, adrenal hemorrhage, maternal meds

Endocrine: hyperinsulinism, hypopit, adrenal deficiency, hypothyroid

Inborn errors of metabolism: carbohydrate disorders, amino acid disorders

Toxic: salicylates, ETOH, oral hypoglycemics, insulin, propanolol

GI: fasting, malabsorption, liver failure, malnutrition