28.1 Pediatric Genitourinary Disorders & Child Abuse: UTI and Vesicoureteral Reflux, Post-Streptococcal GN and Other Nephritides, Nephrotic Syndrome, AKI and HUS, CKD, Congenital Urogenital Anomalies, and Recognizing and Reporting Child Abuse

Why this area matters

The TOS GU competencies are to:

• identify the burden and age, sex and racial predilection of GU disorders;
• reach a diagnosis and differential diagnosis;
• prioritize tests and recognize emergencies;
• manage the case and educate the family.

Child abuse and sexual abuse are part of this area. The physician is often the first to recognize abuse and is legally required to report it.

Urinary tract infection in children

• Who gets it:
  • in infancy, boys, especially uncircumcised boys, are affected more;
  • after infancy, girls are affected much more.
• Organisms: E. coli in most cases; Klebsiella, Proteus, Enterococcus and Pseudomonas in recurrent or complicated cases.
• Presentation:
  • infants have fever without a source, irritability, vomiting, poor feeding and jaundice;
  • older children have dysuria, frequency, wetting and flank pain.
• Diagnosis:
  • urinalysis (pyuria, nitrite) plus culture of a properly collected specimen: catheterization or suprapubic aspiration in infants, because bag specimens are often contaminated;
  • significant growth means 50,000 CFU/mL or more from a catheter specimen, any growth on suprapubic aspiration, or 100,000 CFU/mL or more from a midstream clean catch.
• Treatment:
  • oral antibiotics (such as a cephalosporin) for 7 to 14 days for most febrile UTIs;
  • IV therapy for young infants, toxic or vomiting children;
  • adjust to culture results.
• Imaging:
  • a renal and bladder ultrasound after a first febrile UTI in young children;
  • voiding cystourethrography (VCUG) if the ultrasound is abnormal or after recurrent febrile UTIs, looking for vesicoureteral reflux (VUR, graded I to V);
  • DMSA scans show scarring.
• Prevention of recurrence: treat bladder and bowel dysfunction (constipation, holding), maintain hydration and use antibiotic prophylaxis in selected high-grade VUR.

Acute glomerulonephritis and other nephritides

• Post-streptococcal glomerulonephritis (PSGN):
  • follows group A streptococcal pharyngitis by 1 to 2 weeks or impetigo by 3 to 6 weeks, usually at ages 5 to 12;
  • cola- or tea-colored urine with red cell casts, periorbital edema, hypertension and mild azotemia;
  • low C3 returns to normal within 6 to 8 weeks;
  • ASO or anti-DNase B titers are raised (anti-DNase B is better after skin infection);
  • management is supportive: salt and fluid restriction, loop diuretics and antihypertensives, plus penicillin to eradicate the strain;
  • complications are hypertensive encephalopathy, heart failure and pulmonary edema;
  • most children recover fully.
• IgA nephropathy: gross hematuria 1 to 2 days after a URI (synpharyngitic), with normal C3.
• IgA vasculitis (Henoch-Schonlein purpura): palpable purpura on the buttocks and legs, arthritis, abdominal pain (intussusception risk) and nephritis. Monitor urine and BP for months.
• Lupus nephritis, membranoproliferative GN and Alport syndrome (hematuria with sensorineural deafness and eye findings) are less common.

Nephrotic syndrome

• Definition: heavy proteinuria (urine protein-creatinine ratio of 2 mg/mg or more, or 3+ or more on dipstick), hypoalbuminemia (below 2.5 to 3 g/dL), edema and hyperlipidemia.
• Minimal change disease:
  • the cause in most children aged 1 to 10;
  • normal complement, no hypertension or hematuria in most cases;
  • podocyte foot process effacement on electron microscopy.
• Treatment:
  • prednisone 60 mg/m²/day (2 mg/kg/day) for 4 to 6 weeks, then alternate days with tapering;
  • most children respond (steroid-sensitive), but relapses are common;
  • steroid resistance suggests focal segmental glomerulosclerosis and needs a biopsy.
• Complications:
  • spontaneous bacterial peritonitis (pneumococcus), so give pneumococcal vaccine;
  • thrombosis (loss of antithrombin III);
  • hypovolemia, especially with diuretics;
  • steroid side effects.
• Edema care: salt restriction. Diuretics are used carefully, sometimes with albumin for severe edema.

Acute kidney injury and chronic kidney disease

• Causes of acute kidney injury:
  • prerenal: dehydration from diarrhea, which is the most common cause in children, shock or dengue;
  • intrinsic: acute tubular necrosis, glomerulonephritis, hemolytic uremic syndrome (after EHEC or Shigella dysentery: microangiopathic anemia, thrombocytopenia, AKI), nephrotoxins and leptospirosis;
  • postrenal: posterior urethral valves, stones.
• Management:
  • correct volume;
  • treat hyperkalemia (calcium gluconate, insulin with glucose, salbutamol, binders), acidosis and fluid overload;
  • adjust drug doses;
  • dialysis for refractory hyperkalemia, acidosis, fluid overload, uremia or poisoning.
• Chronic kidney disease in children:
  • mostly congenital anomalies of the kidney and urinary tract (CAKUT: hypoplasia, dysplasia, obstructive uropathy, reflux nephropathy) and glomerular disease;
  • complications are growth failure, anemia, renal osteodystrophy, hypertension and acidosis.

Congenital and acquired urogenital disorders

• Posterior urethral valves:
  • boys with prenatal hydronephrosis and a thick-walled bladder, a poor urinary stream and renal impairment;
  • oligohydramnios causes pulmonary hypoplasia;
  • diagnosed by VCUG and treated by valve ablation.
• Hypospadias: the urethral opening is on the ventral penis, with chordee. Do not circumcise, because the foreskin is used in the repair (at 6 to 18 months).
• Cryptorchidism (undescended testis):
  • common in preterm boys;
  • refer if still undescended at 6 months, for orchiopexy at 6 to 18 months, which reduces infertility and helps cancer surveillance;
  • retractile testes are normal.
• Hydrocele (often resolves by 1 to 2 years) and inguinal hernia (repaired promptly because of incarceration risk).
• Phimosis: physiologic in young boys. Paraphimosis is an emergency that needs reduction. Testicular torsion needs surgery within 6 hours.
• Wilms tumor is covered under oncology.
• Pelvic inflammatory disease in adolescents: sexually active girls are treated with the standard regimen. Confidential counseling and screening for abuse when the girl is young are essential.

Child abuse and sexual abuse

• Physical abuse red flags:
  • a history that is inconsistent, changing or not plausible for the child's development;
  • delay in seeking care;
  • bruises on a non-mobile infant, or on the ears, neck, torso or buttocks;
  • patterned injuries (loop marks, hand slaps, bites);
  • cigarette burns, and immersion burns with stocking or glove distribution and sharp lines;
  • posterior rib fractures and metaphyseal corner fractures, or multiple fractures of different ages;
  • abusive head trauma (shaken baby): subdural hemorrhage, retinal hemorrhages and encephalopathy with little external injury.
• Other forms: neglect (failure to thrive, missed care), emotional abuse and sexual abuse. Sexual abuse may show as genital injury, an STI or pregnancy in a young child, sexualized behavior or disclosure. Many abused children have normal examinations.
• Workup: a full examination with careful documentation, photographs, a skeletal survey in children under 2, head CT or MRI, ophthalmology, bleeding studies and siblings' safety.
• The law:
  • RA 7610 (Special Protection of Children Against Abuse, Exploitation and Discrimination) and its rules require the heads of hospitals and clinics and the attending physician and nurse to report suspected child abuse to the DSWD within 48 hours of knowledge;
  • DOH-designated Women and Children Protection Units provide multidisciplinary care;
  • the child's safety comes first, and the child may be admitted for protection.