Urethral Syndromes in Children

Objectives After completing this article, readers should be able to: Inflammation of the urethra (urethritis) may be due to infection, trauma, allergy, foreign body, or an undetermined factor. Certain characteristics distinguish urethritis in the pediatric population from that in adults. First, urethritis in adults and adolescents has an infectious etiology and always is the result of sexual contact; infectious urethritis in the pediatric age group is uncommon, except in sexually active adolescents or children who have been sexually abused by an adult who has the disease. Second, the variability and nonspecificity of a variety of noninfectious urethral pathologies may mimic infectious urethritis in children.Children who have urethritis may present with irritative voiding symptoms, such as dysuria,urgency, or frequency; possible urethral discharge; initial hematuria; or blood spotting on the underwear. Patients suspected of having urethritis are evaluated with a detailed history,physical examination, urethral smear, or urine culture. In girls, examination may show evidence of vaginitis, which is a common cause of dysuria after urinary tract infection,labial adhesions, or even sexual abuse; in males, results of the examination frequently are inconclusive.In infants, young children, and sexually inactive adolescents, screening tests that have the highest yield include urinalysis and abdominal ultrasonography (US); uroflow is reserved for toilet-trained children. The urine should be examined for evidence of infection or hematuria. Abdominal US can diagnose a variety of abnormalities, including bladder stone or inflammation, ureterocele, foreign body, or tumor. Uroflow is a noninvasive urodynamics test that assesses the ability to initiate voiding on command, quantitates urinary flow, and evaluates postvoid residual. Voiding cystourethrography (VCUG) is indicated when urethral pathology such as posterior urethral valve or urethral stricture is suspected.This common clinical entity mimics urinary tract infection and urethritis and occurs in about 40% of all patients presenting to pediatric urology clinics. Its impact on the social and urologic health of the child often is unrecognized by both general urologists and pediatricians. Symptoms vary widely, but wetness and urinary tract infections are among the most common. Other symptoms include urgency, frequency, infrequency,constipation, and fecal incontinence. There is a strong correlation between vesicoureteral reflux and DV. In addition, upper urinary tract changes such as hydronephrosis and renal insufficiency are not uncommon, especially in severe cases. DV occurs primarily between the ages of 3 and 7 years, although its presence has been suggested, albeit less frequently, as early as the first year of life and beyond puberty.The precise pathophysiology of DV still is unknown. It has been suggested as being due to uninhibited bladder contractions, pelvic floor overactivity, or poorly learned voiding techniques. The impact of acquired DV on the psychologic, social, and urologic health of the child is well documented in the literature. A comprehensive history, physical examination, voiding diaries, and flow-velocity curves(flowrates) are among the currently used methods for diagnosis.The child often passes through a transition phase of voiding, when continence is maintained not by direct central nervous system suppression of detrusor contractions, but by voluntary tightening of the striated portions of the urinary external sphincter. Although the child ultimately acquires the ability to control the detrusor contraction directly by modulating the sensitivity of the reflex in the brain stem, his or her initial efforts at control are directed at stopping the urinary flow that is perceived as unwanted. Children who do not acquire this ability may develop an ingrained pattern of detrusor-sphincter antagonism, resulting in high intravesical pressures, poor emptying,and secondary urinary incontinence.Urinary tract infection is probably the most common precipitant of DV in children. van Gool and associates stated that the inflammatory reaction associated with urinary tract infections may elicit reflexive detrusor and sphincter hyperactivity, causing the normal development of detrusor and sphincter coordination that usually occurs in early childhood to fail,thereby precipitating and sometimes perpetuating DV. Typically, parents note changes in the child’s voiding after a urinary tract infection, and they report that the child is holding urine and sometimes develops urinary retention primarily because of inappropriate learned behavior of tightening his or her bladder outlet complex.Whatever the primary cause for DV, an altered micturitional state results,which may prompt an increase in voiding pressures or simply induce detrusor decompensation and inefficient voiding. Persistently elevated bladder pressure and bladder overdistention may cause increased mucosal disruption and subsequent mucosal permeability. In addition, disruption of the normal laminar flow through the urethra may cause bacteria to flow back from the urethra (“milk back”phenomenon). This vicious cycle may lead to more severe bladder and renal injuries and recurrent urinary tract infections. The diagnosis of DV is suggested only by a history of the child’s voiding pattern and symptoms and does not necessarily require complex urodynamic studies.There is no apparent pathology,injury, or congenital malformation in DV. Ancillary tests, such as urodynamic studies and magnetic resonance imaging of the spine, are employed only when there is a high suspicion of neurogenic bladder dysfunction. These studies may not help to establish or refute a diagnosis of DV.Children who have DV may be helped with a behavioral modification approach that involves: The principal determinant of the success of bladder retraining is patient motivation. Teaching is initiated in the clinic if the diagnosis of DV is suspected, but repeated positive reinforcement of the retraining regimens invariably are needed for both the parents and the children. van Gool et al reported an effective treatment program involving a 10-day inpatient course that included urodynamic studies and behavioral therapy.Children who exhibit a persistent inability to relax their sphincters require a more intensive approach that involves relaxation techniques and electromyographic biofeedback from the pelvic floor. Biofeedback has been used to treat DV in children, and even though it is time-consuming and labor-intensive for the patient and therapist, the reported success rate is high.Pharmacologic treatment using anticholinergics may be necessary if uninhibited bladder contractions are documented by urodynamic studies. Antibiotics may be indicated in cases of vesicoureteral reflux or a history of recurrent urinary tract infections. The use of alpha-blockers is controversial.Bulbar urethritis is a fairly common urologic problem in adolescent boys that is associated with dysuria, meatal blood spotting, and microscopic hematuria. Typically, the children are generally healthy other than the recurrence of urinary symptoms that usually last for more than 1 week. Williams and Mikhael first described this entity in 1971, but no further reports have followed. The etiology is not known. Williams and Mikhael suggested a viral cause; Whitaker found a 46-nm particle in the urine of those who had urethritis by electron microscopy, but no viral particles in the biopsy specimen of the inflamed urethrae. Dewan et al suggested that bulbar urethritis is an inflammatory urethritis, as seen in Reiter syndrome,but without the commonly associated uveitis or arthritis. On the other hand,because bulbar urethritis tends to resolve after the onset of puberty,Docimo and associates related anterior urethritis to the prepubertal hormonal milieu.Changes seen with anterior urethritis on cystoscopic examination consist of squamous metaplasia in the anterior urethra, ragged and inflamed mucosa confined to the bulbar urethra,ulceration, and pseudopolyp. Urethral strictures may develop in extreme cases,but there is a debate about whether the stricture formation results from the disease or the intervention of voiding cystourethrography or cystoscopy.Evaluation of patients who have bulbar urethritis includes taking a history and performing a physical examination. A urine flowrate is performed to rule out urethral stricture or urethral meatal stenosis, and urinalysis and urine cultures are used to rule out urinary tract infection. US of the kidneys and bladder is reserved for patients who have frequent and lengthy recurrences. We usually avoid cystoscopy and even passage of a catheter to perform cystourethrography to lessen the risk of stricture formation. With typical symptoms of bulbar urethritis, a normal flowrate,negative urine culture, and normal US results, the treatment is conservative. Antibiotic therapy is not recommended;there is no evidence that it affects the course of the symptomatic period. Idiopathic urethritis in male children is a benign, self-limiting, chronic condition. Therefore, patients and their parents can be reassured but need to know that symptoms might persist for a long time.Urethral strictures in children can be divided into two categories:acquired and congenital. Acquired urethral strictures due to urethral instrumentation comprise the majority of cases, with subclassifications of inflammatory and iatrogenic/traumatic. Inflammatory strictures are due to urethritis associated with the use of indwelling catheters; iatrogenic strictures occur following cystoscopy,traumatic urethral catheterization, or surgery such as for hypospadias. Congenital urethral strictures are rare,and they are diagnosed only if the stricture is identified at the time of initial evaluation, and there is no history of prior urethral injury,instrumentation, or inflammation. Finally, urethral strictures may occur following a straddle injury or pelvic fracture.Children who have urethral strictures present with obstructive and irritative urinary symptoms, such as acute urinary retention, dysuria, hesitancy, or weak urine stream. The diagnosis is usually made with retrograde urethrography or cystoscopy. Treatment of pediatric urethral strictures is surgical and includes dilatation, endoscopic urethrotomy (cold knife, electrical, or laser), and repair (excision of urethral scar and reanastomosis).Chlamydia trachomatis is the most common reportable sexually transmitted infection among sexually active adolescents and young adults. It is estimated that 25% to 35% of the adolescent population is sexually active and unlikely to use condoms. The prevalence of asymptomatic urethritis in boys is unknown, but it is believed to be fairly uncommon.Young males who present with infectious urethritis usually complain of some degree of stinging and burning on urination, with or without a urethral discharge, which may vary(according to the causative agent) from a clear mucous fluid to a copious,purulent-looking discharge. An average of four or more polymorphonuclear leukocytes per oil immersion field in a Gram stain of an endourethral swab specimen establishes a diagnosis of urethritis. More than 10 leukocytes per high-power field in the initial 15 to 20 mL of a first-catch urine specimen also is strongly suggestive of urethritis, as is a positive urine leukocyte esterase test result.GU is common in adolescent males and females between 15 and 19 years of age. It may be asymptomatic or present with a mucopurulent discharge, and the incubation period for symptomatic disease is approximately 4 days. The child may have dysuria and pyuria, with a sterile urine culture when routine urine culturing techniques for normal urinary tract pathogens are used. A Gram stain of the discharge followed by a urethral meatal culture will confirm the diagnosis. If the discharge is profuse, there is little difficulty obtaining a specimen for culture. If none is observed, gentle squeezing of the distal urethra and insertion of a sterile cotton swab into the meatus,then into an appropriate culture medium may yield a specimen. Urine culture identifies the causative organism only if collected properly. If the male is uncircumcised, he should be instructed to retract the foreskin, hold it for the duration of the collection, then wash the glans carefully with water and dry with sterile gauze. The diagnosis is confirmed by observation of the typical gram-negative diplococci either within or attached to neutrophils.Treatment of GU includes therapy for C trachomatis because this pathogen can be recovered from approximately 20% of men who have GU. Among the therapeutic options for GU are 125 mg ceftriaxone intramuscularly or azithromycin 1 g orally in a single dose.C trachomatis is the cause of almost 50% of cases of symptomatic NGU; 10% to 20% of cases are caused by Ureaplasma urealyticum, and another 10% appear to be due to Trichomonas vaginalis. The incubation period for symptomatic chlamydial urethritis is 7 to 14 days. Patients present with dysuria and urethral discharge, which tends to be white, gray, or sometimes clear, in contrast to the more purulent discharge observed with gonococcal urethritis. Urethral or perineal itching,associated with urinary frequency, also may occur. Isolating the organism in culture and excluding the presence of Neisseria gonorrheae on Gram stain allows the definitive diagnosis of chlamydial urethritis or NGU.Treatment options for NGU include either oral doxycycline (200 mg/d in a divided dose) for 7 days or azithromycin 1 g in a single dose.

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