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All posts with tag: "gu"

Tips and Tricks

A trio of recent publications on pediatric UTI offer some insights. First, Mattoo et al offer a review of UTI diagnosis and management in children. Nadeem et al studied the optimal WBC cutoffs for diagnosing UTI, balancing overdiagnosis/overtreatment with underdiagnosis/missed UTIs, based on the specific gravity and found them to be: 3 WBC/hpf for spec grav < 1.011, 6 WBC/hpf for 1.011-1.020, and 8 WBC/hpf for spec grav > 1.020. And Liang et al reviewed 2144 PED visits in < 2yo and calculated likelihood ratios and posttest probabilities for various urinalysis findings. UTI prevalence was 9.2%, which the authors used as the pretest probability. Likelihood ratios for leukocytes were: 1+ 2.79. 2+ 7.53, 3+ 37.68. Nitrite positivity carried a LR of 25.35. WBC/hpf at 5-10 had a LR of 1.2 (95CI 0.7-2.04), 10-20 LR 1.82, 20-50 LR 11.18. Few bacteria had an LR of 1.46, moderate 6.05, many 14.04. 

To remember the difference in antibiotic regimens for chlamydia cervicitis / urethritis vs pelvic inflammatory disease, rap this in your head: Ceph 2C50 for GC is nifty; give Zith 1 gram for the chlam, but doxy 14 days BID is needed for PID
Staying with the topic of urine... investigators at University of Pittsburgh have derived and validated a UTI risk calculator for patients aged 2-23 months. The calculator (UTICalc) is linked from the On Shift page of PEMsource under the heading Neonatal / Infant, and can be found at The study by Shaikh et al was published online on April 16, 2018 at JAMA pediatrics here. Some highlights: derived on consecutive 2-23mo old febrile patients evaluated in ED for UTI, 542 with UTI and 1144 matched controls without UTI. Validated on a dataset of 380 patients, 30 with UTI. Investigators estimate sensitivity of UTICalc at 95-100% and state that use of the calculator results in approximately 10 patients tested for every 1 UTI found; UTICalc outperformed the current AAP algorithm in both of these outcomes. Users can also enter urinalysis dip, micro, and gram stain results to obtain post-test probabilities. Investigators suggest testing when pre-test probability is 2% or higher, and treating when post-test probability is 5% or higher. Further validation is warranted, but UTICalc may be useful in shared decision making with parents to give a ballpark risk estimate.
Nothing slows down the ED flow like waiting for the urine flow of an infant or toddler. Whether or not to screen for UTI with a clean catch urine vs obtain a catheterized specimen will be left for another discussion, but here are some of the latest techniques described for obtaining clean catch specimens. (For all, clean genital area thoroughly first) "CCU" procedure, first described by Herreros Fernandez et al, Arch Dis Child 2013;98:27, 80 infants aged < 30 days. Patient held under armpits with legs dangling in upright position. Suprapubic area gently tapped at 100 taps/minute x 30 seconds, followed by light circular massage of the lower back x 30 seconds. Repeat these maneuvers until urine collected. Successful in 86% of the infants with median time to collection 45 seconds. Labrosse et al, Pediatrics 2016;138(3):320160573 studied this CCU method with the addition of another person flexing the hips of female children, 126 infants < 6 months old. CCU method successful in providing urine sample within 300 seconds in 49%, median time 45 seconds. More successful in < 3 months old than 3-6 months old. "Quick-Wee" method, Kaufman et al, BMJ 2017;357:j1341, 354 infants aged 1-12mos With patient supine, suprapubic skin was rubbed with gauze soaked in cold saline. 31% voided within 5 minutes using Quick-Wee vs. 12% in the standard collection group. Finally, Naimer in Pediatr Emerg Care 2017;33:446 describes cutting a slit in an infant's diaper to push the urine collection bag through when obtaining a bag urine. This both helps to secure the bag and allows parents and nurses to see when the specimen has been obtained.
Your local hospital cafeteria can be a useful resource in managing your PED patients:
  1. Sugar liberally applied to the edema of a paraphimosis or rectal prolapse may help decrease swelling and improve reduction efforts
  2. A mayonnaise packet provides useful lubricant for removing a tight ring
  3. Tannins from a tea bag (particularly black tea) can help clotting with post dental extraction bleeding (place a moistened tea bag in the socket and have the patient apply pressure by biting down)
  4. A packet of sugar + 10 mL sterile water = make your own sucrose solution for treatment of pain associated with procedures in infants
Know of any more? Comment below!
A young girl comes in c/o dysuria and the urine is stone cold normal. What else can explain her symptoms? (BTW, you must do a GU exam at this point). Adhesions (labial) Bubble bath (and other soaps, irritants) Candida (particularly if recently on antibiotics, or at risk for new onset diabetes) Detergent (harsh laundry detergent, new tight clothing / underwear) Enterobius (aka pinworms) Foreign body (typically toilet paper) Gonorrhea & chlamydia (in sexually active or sexually abused) Hygiene, poor (teach girls to wipe front to back, consider having them sit on toilet backwards to urinate, especially if they are overweight/obese, to encourage complete voiding and keep urine from collecting in vagina) Irritation (masturbation is a common normal behavior in preschoolers)

PEM Questions

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You are seeing a 4 year old boy with PMH of two UTIs and frequent episodes of otitis media. He has dysuria, frequency, straining to void, a poor urinary stream, and large volumes of urine when he does void. He is circumcised and his external genitalia exam is normal.

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(Click the link to comment and to vote - voting not working through email, sorry!) You are seeing a 2 year old boy with complaint of penile pain for 2 days. He is previously healthy, fully immunized, afebrile, and has not had this before. He has been able to urinate although he complains of pain with urination. There is no history of trauma to the area. He is uncircumcised. Exam shows the tip of the foreskin to be swollen and erythematous and tender to the touch. There is no discharge, evidence of trauma, discoloration of the penile shaft or perineum, nor inguinal lymphadenopathy. The testes are descended and nontender. [yop_poll id="157"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="151"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="144"]
(Click the link to comment and to vote - voting not working through email, sorry!) An 8yo boy presents with dribbling urination and pain with urination. When he urinates he sees his foreskin balloon out. On exam, he has phimosis. Per parents, they were previously able to retract his foreskin for hygiene purposes, but now they can’t. The patient is able to urinate and ultrasound shows no significant post-void residual. He is afebrile and urinalysis does not show evidence of UTI. [yop_poll id="140"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="104"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 19yo man was seen in the ED 2 weeks ago with a painless lesion to his penis. He is sexually active with men, has had 2 recent partners, and “sometimes forgets” to use condoms. At that time testing for HIV, RPR, gonorrhea, and chlamydia urine NAT were performed at the time and he was treated empirically with IM bicillin for presumed chancre of syphilis and empiric IM ceftriaxone for gonorrhea. All of the labs were subsequently negative. He now returns with bilateral tender inflamed inguinal adenopathy. His penile lesion resolved after a few days. [yop_poll id="68"]
(Click the link to comment and to vote - voting not working through email, sorry!) [yop_poll id="53"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 5 year old uncircumcised boy is brought in because his parents are concerned that they cannot retract his foreskin. On exam he has phimosis, but there are no signs of inflammation or swelling and no palpable scarring or fibrosis. The patient is asymptomatic and has experienced no ballooning, dysuria, incontinence, dribbling, or recurrent balanoposthitis or UTI. [yop_poll id="35"]
(Click the link to comment and to vote - voting not working through email, sorry!) A 15 year old girl is brought in by her uncle for a chief complaint of vaginal discharge (he explains that her parents are working and unable to bring her in). She has yellow vaginal discharge and cervical motion tenderness on exam. Her pelvic exam is otherwise unremarkable. She has a linear bruise on her neck, some circular marks on her right dorsal hand, and some linear hyperpigmented marks on her right volar wrist. She shrugs her shoulders when asked how these occurred. Her uncle states that she “does it to herself.” She avoids eye contact, is not very conversant, and her uncle answers most of her questions for her. She shakes her head “no” when asked about depression or suicidality. [yop_poll id="32"]
A 5yo uncircumcised boy comes in because his parents are unable to retract the foreskin of his penis. They have not been able to retract it ever, but now note also that he is having ballooning of the foreskin when he urinates. On exam, the opening of the foreskin is very tight. Appropriate treatment includes: A. Forceful retraction of the foreskin to break any adhesions B. Topical steroid cream and close follow-up C. Topical estrogen cream and close follow-up D. Emergent consultation with a urologist for immediate circumcision E. Reassurance that the condition will resolve by age 10 years


(Click the link to comment and to vote - voting not working through email, sorry!) Note: conundrums are not meant to have a “right” answer – they are to see how most people are practicing. Would love your comments also regarding your thought processes and the evidence behind your decisions. We can learn from each other! For pediatric blunt trauma patients... [poll id="23"]

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