Tiffani J. Johnson and Rhett Lieberman
HEMATURIA
Hematuria is the presence of blood in the urine, which can be gross (visible to the naked eye) or microscopic. Microscopic hematuria is defined as the presence of 3 to 5 RBCs/HPF on at least two of three examinations over a 2- to 3-week period, and is a common finding in the pediatric population, with a prevalence of 0.5% to 2%, although less common than in adults, where the prevalence is up to 21%. Gross hematuria presents as a discoloration of the urine that is either red/pink or cola or tea colored. It is important to note that a small amount of blood (1 mL in 1,000 mL of urine) can cause discoloration of the urine (1). Gross hematuria is noted in about 0.1% of children, as compared to 2.5% in adults (2). Distinguishing emergent reasons for evaluation in the pediatric patient is essential for the emergency practitioner.
CLINICAL PRESENTATION
Microscopic hematuria is often an incidental finding in children during evaluation for genitourinary (GU) symptoms. The primary tool for screening is a urine dipstick; a result of blood 1+ and greater is considered positive. The dipsticks used for detection of blood in the urine are very sensitive in detecting red blood cells (RBCs) and minute amounts of free hemoglobin and myoglobin. Dipstick screens should be confirmed with microscopic examination of the urine to exclude false-positive and false-negative results.
DIFFERENTIAL DIAGNOSIS
The causes of hematuria are numerous, and in the pediatric population are more often medical than surgical in nature (3). In developing a differential diagnosis, in addition to classifying hematuria as gross or microscopic, clinicians must be able to differentiate the origin of the hematuria. In children gross hematuria is often glomerular in origin. Glomerular bleeding tends to be associated with cola- or tea-colored urine (30% of patients), whereas bleeding from the lower tract and bladder presents with red- or pink-colored urine. Furthermore, with glomerular hematuria there are often findings of proteinuria, red cell casts, and red cell dysmorphology, coupled with systemic findings such as hypertension and edema (1,4). The passage of blood clots usually points to the bladder or urethra as the source of bleeding (3,5).
Acute glomerulonephritis (AGN) results from immunologic effects on the glomerular tissue and is divided into three broad categories: postinfectious, due to intrinsic renal disease, and due to systemic disease (Table 243.1). Postinfectious acute glomerulonephritis (PIAGN) is a common cause of pediatric glomerulonephritis and the most common cause of glomerular gross hematuria in the pediatric patient. It has a peak incidence between the ages of 2 and 6 years and frequently follows streptococcal infections of the skin or pharyngitis with certain nephrogenic strains of group A β-hemolytic streptococci.Characteristically, there is a latent period between the streptococcal infection and the onset of nephritis, which can be 8 to 14 days for pharyngitis and 14 to 21 days for skin infections (4,6).
TABLE 243.1
Causes of Glomerulonephritis
Urinary tract infection (UTI) represents the most common cause of gross hematuria and is often associated with dysuria, frequency, or abdominal pain (7). A history of recent trauma, including catheterization, masturbation, urethral foreign bodies, or recent strenuous exercise (running, bicycle riding) can explain transient hematuria (8). Any past history of renal colic or a family history of nephrolithiasis or hypercalciuria should be elicited. Specific pulmonary symptoms, such as hemoptysis (Goodpasture syndrome), or the triad of sinusitis, AGN, and pulmonary infiltrates (Wegener granulomatosis) may provide important clues to a diagnosis.
Pseudohematuria is caused by substances other than blood that discolor the urine (Table 243.2). This may include oxidizing contaminants, such as bacterial peroxidases from a UTI, or a delay in reading the dipstick. Newborns often present with the parents’ concern for a red or pink discoloration in the front of the diaper, often referred to as “brickdust urine,” which is caused by urate crystals deposited in the diaper. Certain foods (e.g., beets, blackberries, rhubarb), and medications (e.g., rifampin, cefdinir) can also cause urine discoloration that is mistaken for hematuria (4,7). A positive dipstick reaction in the absence of RBCs on microscopy can be caused by myoglobinuria (rhabdomyolysis) or hemoglobinuria (seen in conditions causing hemolysis). In the menstruating girl, vaginal bleeding can be confused with urinary blood. A catheterized urine specimen may be necessary to determine the source of the bleeding. It should also be noted that a false-negative dipstick reading can occur when the urine has a high specific gravity or contains large amounts of reducing substances, such as ascorbic acid.
TABLE 243.2
Cause of Pseudohematuria
The differential diagnosis for childhood hematuria is listed in Table 243.3, and can be remembered by using the alphabetic sequence A through I (9).
TABLE 243.3
Differential Diagnosis for Childhood Hematuria
ED EVALUATION
The diagnostic approach to the pediatric patient with hematuria should incorporate specific elements of both the past and family history. The workup differs from that in adults since renal and urologic malignancies are far less common (10,11). The history should identify antibiotics use, chemotherapy, radiation for malignancies, exposure to tuberculosis, or the use of over-the-counter medications, some of which can cause interstitial nephritis. Rash or arthritis can be found in systemic vasculitides such as systemic lupus erythematosus (SLE) or Henoch–Schönlein purpura (HSP). Umbilical catheterization in the neonatal period, often in premature infants, can cause renal vein or artery thrombosis, which may result in hematuria (12). Inquiry into family history can uncover other potential etiologies. For example, a family history of hearing deficits and renal failure may suggest Alport syndrome. Other diseases that have a familial association include SLE, sickle cell anemia, hemophilia, IgA nephropathy, and other coagulation factor deficiencies.
The physical examination is often nonspecific, but several elements deserve attention and are useful in diagnosis and management. An elevated blood pressure should alert the physician to the possibility of a more severe underlying condition, such as aortic interruption or intrinsic renal disease. The child’s height and weight should be plotted and past values should be carefully reviewed to detect failure to thrive associated with long-standing acidosis or chronic renal insufficiency. Evaluation for periorbital and genital edema is important.
Pulmonary findings on auscultation, in addition to exercise intolerance or dyspnea, may provide clues to fluid overload. Costovertebral angle tenderness may indicate a UTI. Recent trauma maybe suggest by findings of flank bruising and pain. Examination of the abdomen for masses is critical for the identification of renal and urologic malignancies (Wilms tumor being the most common in pediatrics), polycystic kidneys, or hydronephrosis (11). The examination of the skin and joints may provide evidence of arthralgias and pallor or rashes, which may be significant in diseases such as hemoglobinopathies, leukemia, HSP (petechial or purpuric lesions on the lower extremities), or SLE (malar rash) (7). The genital examination should be included to identify abuse or trauma, discharge, or meatal stenosis, all of which can cause hematuria.
The child with a history of flank, back, or abdominal trauma and gross hematuria should undergo renal imaging to identify renal injury. Ultrasound is useful for detecting free fluid in the abdomen in the case of trauma, but computed tomography (CT) provides more specific information for diagnosing and grading renal injuries. Gross hematuria is not the only presentation for significant high-grade renal injuries. In fact, significant injuries may present with microscopic hematuria or an entirely normal urinalysis. Therefore, the decision to pursue imaging for renal injuries should not be based on urinalysis alone, but on a combination of clinical status, physical examination findings, and mechanism of injury (13). A high index of suspicion must be maintained for lesions of the urinary tract in patients with gross hematuria after minimal-force blunt abdominal trauma. Some authors recommend a CT scan of the abdomen and pelvis for patients with 50 or more RBCs on urinalysis, hypotension at the time of emergency department (ED) presentation, or a serious mechanism of injury such as high-speed motor vehicle accident deceleration injuries (5). If blood is noted at the urethral meatus, a retrograde urethrogram must be done prior to catheterization to verify urethral integrity.
Dysuria and urinary frequency, or the presence of systemic signs (fever, vomiting, and abdominal pain), should suggest the possibility of a UTI, including pyelonephritis, and a screening urinalysis and urine culture must be sent. The child with gross hematuria and severe episodic flank or abdominal pain should be evaluated for urolithiasis. The literature on using radiography to diagnose urolithiasis in pediatrics describes varying sensitivities and predictive values for different radiologic modalities. Plain radiography is insufficient to detect stones and ultrasound can detect intrarenal stones, especially those more than 5 mm in diameter (14). Noncontrast CT is the gold standard, but concerns about the long-term effects of radiation exposure have led many clinicians to reserve CT for patients with persistent or refractory symptoms, or a nondiagnostic US. Urologic consultation is appropriate if a stone is detected. Since a metabolic abnormality can be identified in 40% to 50% of cases of urolithiasis in children, a basic metabolic panel and urine calcium determination are an appropriate part of the initial workup (15,16).
Gross hematuria combined with the presence of proteinuria suggests glomerulonephritis. Proteinuria should not exceed 2+ if the only source of protein is from the blood. Postinfectious glomerulonephritis is the most common cause of acute nephritis in the pediatric population. Pertinent laboratory evaluation includes a complete blood count (hemolytic–uremic syndrome), and culture from the throat and skin should be sent in an effort to isolate a nephrogenic strain of streptococcus, although these cultures are usually negative at the time of diagnosis. Elevated anti-streptolysin O (ASO) titers suggest recent infection (2 to 6 weeks); however, the ASO titer may not rise after streptococcal pyoderma. Anti-DNase B can be elevated for up to 6 months after infection, and is the best single test to detect recent streptococcal infection. The complement C3 level is low in acute poststreptococcal glomerulonephritis, membranoproliferative glomerulonephritis, and SLE, but returns to normal in 6 to 8 weeks (4,6). Further immunologic workup, including antinuclear antibody tests, may be helpful if a diagnosis of underlying systemic disease is being entertained (7).
Less common causes of gross hematuria include hypercalciuria, nephrocalcinosis, sickle cell trait, and glomerular basement membrane defects. Diagnosis begins with a urine Cr/Ca ratio or a 24-hour urinary calcium excretion, serum creatinine, and renal sonography. Consultation with a pediatric nephrologist is recommended if the underlying etiology in unclear on the initial evaluation.
KEY TESTING
• Urinalysis with verification of hematuria by microscopic evaluation
• For potential renal trauma: CT or ultrasonography, CT is preferred for more accurate grading of injury
• For nephrolithiasis: ultrasonography or CT, metabolic panel, and serum calcium
• For glomerulonephritis: skin culture, throat culture, ASO titre, anti-DNase B and C3 complement levels; CBC for possible HUS
ED MANAGEMENT
Management of hematuria depends on the specific etiology involved. Pain management must be addressed in the uncomfortable child. Ketorolac and morphine are the mainstays of analgesia for renal colic. Medical expulsive therapy with agents such as tamsulosin has not been well studied in the pediatric population (17). Asymptomatic hematuria does not require acute ED management, with the exception of UTI, in which appropriate antibiotic therapy is needed (see Chapter 288).
In PSAGN, no specific therapy has been found to influence healing of the glomerular lesions, and much of the treatment is supportive. Antibiotics do not alter the ultimate course of the initial streptococcal disease (with the exception of prevention of rheumatic fever) but may decrease the spread of nephrogenic strains of streptococcus in patients with positive cultures. Thus, penicillin should be administered to the nonallergic patient. For the child with acute renal failure, hypertension, or hyperkalemia, appropriate treatment should be initiated promptly, in consultation with a nephrologist (18).
Up to 85% of patients with postinfectious glomerulonephritis have edema and hypertension, in addition to hematuria, and up to 10% to 30% may have hypertensive encephalopathy presenting with headache, nausea, vomiting, seizures, or transient cortical blindness (6). For hypertensive emergencies in children with PSAGN, therapy should be gradual and controlled. Drugs such as diazoxide, hydralazine, labetalol, loop diuretics, and calcium channel blockers are increasingly chosen because of their quick onset of action. However, decreasing blood pressure by more than 20% to 25% can cause decreased cerebral perfusion and has the potential to cause stroke. In patients with glomerulonephritis that is nonstreptococcal, corticosteroids or cytotoxic agents may be prescribed in consultation with a nephrologist.
Less common causes of hematuria in children include coagulation abnormalities and some anatomic or vascular problems (7). These, and other conditions requiring advanced workup (Table 243.4), should be referred to a pediatric nephrologist or urologist.
TABLE 243.4
Evaluation of the Child with Hematuria
CRITICAL INTERVENTIONS
• The decision to order renal imaging after blunt trauma should be based on clinical status, history, and mechanism of injury and not on the urinalysis alone.
• Acute management of pediatric hypertensive emergencies should be gentle and controlled, often in consultation with a pediatric nephrologist.
DISPOSITION
Referral to a pediatric nephrologist should occur for children with gross hematuria, coexisting significant proteinuria, hypertension, abnormal kidney function tests, persistent hypocomplementemia, findings suggestive of a systemic disease, or a family history of glomerulonephritis, nerve deafness, chronic renal failure, end-stage renal disease, or familial hematuria. If parental anxiety is high, referral to a pediatric nephrologist may help alleviate fears and serve as additional reassurance to the family that dangerous and treatable conditions have been ruled out by the emergency physician. Parents are often concerned that their child is losing large amounts of blood due to the color of the urine, and they should be reassured and reminded that as little as 1 mL of blood in 1,000 mL of urine can make the urine red (3,7,19).
Patients with newly diagnosed renal disease should be admitted with pediatric nephrologist consultation, given the possible complications, including hypertension, hyperkalemia, and acute renal failure.
It is important to remember the most common causes of microscopic hematuria without casts or proteinuria are benign and do not require immediate treatment. The overall prognosis for these children is very good. A poor prognosis is, however, associated with proteinuria at presentation, persistent hematuria, and hypertension.
Common Pitfalls
• Failure to perform a urine dipstick followed by formal urinalysis to confirm the presence of blood in the patient with “red urine” can lead to unnecessary further laboratory testing.
• Failure to obtain relevant information such as a history of recent pharyngitis, trauma, or renal stones
• Failure to detect proteinuria, hypertension, or subtle signs of fluid overload
• Failure to recognize that the presence of polymorphonuclear leukocytes and renal epithelial cells may be the only abnormalities in early AGN
• Failure to include AGN in the differential diagnosis of hematuria, particularly when there are other signs such as edema
• Failure to send a urine culture when there are signs and symptoms of UTI
DYSURIA
Many GU conditions can present with dysuria, the most common being UTI, sexually transmitted infection (STI), and vaginitis. Rarely, dysuria may be a presenting complaint associated with systemic disease.
CLINICAL PRESENTATION
Dysuria is defined as pain with urination and may be the chief complaint of a verbal child (≥2 years), or the perceived complaint reported by the parent of a preverbal child who cries with urination or diaper changes. The clinical presentation of dysuria varies depending on the underlying cause.
DIFFERENTIAL DIAGNOSIS
Table 243.5 outlines common causes of dysuria.
TABLE 243.5
Causes of Pediatric Dysuria
UTI is defined as infection of the bladder (cystitis), kidney (pyelonephritis), or both. UTIs account for 5% to 14% of pediatric ED visits in the United States (20). The clinical presentation varies depending on the age of the child. Preverbal children are more likely to present with fever and nonspecific symptoms such as vomiting or fussiness, while older children are more likely to present with specific urinary symptoms such as dysuria, frequency, urgency, and suprapubic abdominal pain. Findings most useful for identification of a UTI include history of a previous UTI, fever, suprapubic tenderness, and lack of circumcision in males. In verbal children, abdominal pain, back pain, dysuria, frequency, and new-onset incontinence may be findings associated with UTI (21). Pyelonephritis is typically associated with a fever ≥38.5°C, while children with cystitis are less likely to have fever.
STIs are a common cause of dysuria; the reported ED prevalence of STIs in symptomatic adolescent patients has been as high as 26% (22). Neisseria gonorrhoeae and Chlamydia trachomatis are the most common causes in adolescents while Trichomonas vaginalis occurs less commonly. Urethritis is a localized inflammation of the urethra, usually caused by infection. When left untreated, up to 40% of STIs will lead to more serious conditions including pelvic inflammatory disease (PID), chronic pelvic pain, and even infertility (22). In addition to urethritis and PID, ulcerative STIs, such as herpes or syphilis, may present with dysuria.
Vulvovaginitis presents with vaginal discharge and vulvar irritation, typically with redness, burning, itching, and soreness. Dysuria is usually due to the pruritus and excoriation. Recurrent vulvovaginitis can also be bacterial, and occurs most commonly in prepubertal girls aged 2 to 7 years, due to low estrogen levels (23). Infections from Candida, Trichomonas, and Gardnerella are uncommon in prepubertal girls. Young girls can have vulvar irritation without virginal discharge, usually due to atopic or irritant dermatitis. Common local irritants include fragranced soaps, bubble bath, laundry detergents, and fabric softeners. Physical examination is often unremarkable, or may reveal mild genital erythema without discharge. In some cases, excoriations caused by vulvar irritation may lead to labial adhesions as the skin heals.
Pruritus due to pinworm infection may also be reported as dysuria. Symptoms tend to be worse at night, when worms emerge from the anus and lay eggs around the anus and vaginal area. Nausea, vomiting, and abdominal pain may develop if there is a large worm burden.
Additional causes of dysuria in the pediatric population worthy of consideration based on the history and physical examination include minor trauma from self-exploratory behavior, masturbation, or sexually activity. A foreign body may cause pain or pruritus that may be reported or misinterpreted as dysuria. Examples include retained toilet paper from poor hygiene, or small objects, such as a bead or toy, in a younger child. Rarer causes include urinary stones, idiopathic hypercalciuria or hyperuricosuria, dysfunctional voiding, and urethral structure.
Systemic conditions as a cause of dysuria are uncommon, but may be potentially serious. The mucocutaneous lesions of Stevens–Johnson syndrome can involve the genitalia. Reactive arthritis presents with arthritis, conjunctivitis, and urethritis, and occurs more commonly in sexually active males. Behçet disease is a multisystem vasculitis that can present with oral and genital ulcers, as well as ocular, joint, gastrointestinal, skin, and neurologic involvement.
ED EVALUATION
The history is critical in guiding the approach to a child with dysuria. Important points to note include associated GU symptoms such as hematuria, frequency, urgency, hesitancy, incontinence, burning with urination, or vaginal or penile discharge. Systemic symptoms, including the duration and height of fever, joint pain, ocular complaints, or rash, are important to identify. Vomiting, abdominal pain, suprapubic pain, and back pain should also be noted. All adolescents should have a sexual history obtained with the parents outside the room. However, the sexual history may be unreliable in this population, so history alone should not guide management decisions. A previous history of UTI and STI should also be documented. The physician should inquire about any exposures to chemical irritants that may cause dysuria (e.g., perfumes, soaps, bubble bath, laundry detergents, or fabric softeners).
In younger children, consider beginning with auscultation of the heart and lungs before beginning any potentially uncomfortable portions of the examination. Care should be taken to note any oral lesions, which can be seen with systemic illness such as Stevens–Johnson syndrome or Behçet disease. Examine the abdomen for tenderness over the suprapubic region and right, and left lower quadrants, which may suggest cystitis. Tenderness on palpation at the costovertebral angle suggests pyelonephritis. The skin should be examined for rashes.
A GU and perianal examination should be performed to evaluate for discharge, lesions, vesicles, ulcerations, gross anatomical abnormalities (e.g., labial adhesions), or the presence of a foreign body. In males, the scrotum should be examined for swelling, redness, or tenderness to palpation. If the patient is uncircumcised, the foreskin should be examined for signs of inflammation. The female GU examination should be performed in the frog-leg position on the examination table, or in a less cooperative child, on the parent’s lap. The child should lie on her back, bend the knees, place the feet together, and open the legs like a frog with the lateral aspect of knees touching the examination table if possible. Inspection should be performed using labial traction by gently grasping the labia majora and pulling laterally and downward to improve visualization. If better visualization of the vaginal vault is needed, consider the knee-chest position by having the child lie on her face and chest with the buttocks in the air and with the knees bent and 6 to 12 in apart. The underwear should also be inspected for signs of discharge.
In addition to the external GU examination, a bimanual examination should be performed in all sexually active adolescent females to assess for cervical motion tenderness or uterine or adnexal tenderness. In the setting of advanced diagnostic testing for STIs, invasive speculum examinations are not always routinely indicated for dysuria. The speculum examination should be performed in adolescent females with accompanying vaginal bleeding, suspected foreign body, pregnancy, or persistent symptomatic vaginal discharge.
The physician must be able to interpret the results of the urinalysis, initiate antibiotic treatment when appropriate, and ensure follow-up of urine culture results. The need for further diagnostic studies should be guided by the history and physical examination, coupled with the physician’s index of suspicion for other entities.
UTI is diagnosed based on the presence of significant bacteriuria and pyuria on an appropriately collected urine specimen. Significant bacteriuria is characterized by any organisms on a suprapubic specimen, at least 50,000 colony-forming units per milliliter (CFUs/mL) in a catheterized specimen, or at least 100,000 CFU/mL in a clean-catch specimen. Escherichia coli is the most common pathogen causing UTI. Other common organisms include Klebsiella, Proteus, Enterobacter, Citrobacter, Staphylococcus saprophyticus, Enterococcus, and adenovirus. Pending culture confirmation, urinalysis results can aid in making a presumptive diagnosis and determining the need to begin antibiotic therapy. Significant pyuria is characterized by at least 10 white blood cells (WBCs) per microliter on an enhanced unspun urinalysis, or 5 WBC per high power field on a centrifuged specimen. Dipstick urinalysis has a specificity of 93%. When it is negative for both nitrite and leukocyte esterase, the negative likelihood ratio (LR) for UTI is 0.2; if either is positive, there is a positive LR of 6, and the LR is 28 if both are positive (24).
Distinguishing between an STI and a UTI based on history, physical examination, and urinalysis can occasionally be challenging, given that there is often an overlap in symptoms (25,26). All adolescent patients presenting with dysuria should have a urine pregnancy test and also be tested for STIs by obtaining cervical swabs for culture. Alternatively, the emergency physician can send nucleic acid amplification testing (NAAT) for N. gonorrhoeae and C. trachomatis from a self- or physician-obtained cervical swab, vaginal swab, or urine specimen. The sensitivity of NAAT testing depends on the collection method; a urine specimen is more sensitive when obtained at the initiation of urination without cleaning the perineum. Testing and treatment for Trichomonas vaginalis in both males and females should be strongly considered based on the community prevalence of disease. Patients with ulcerative lesions on examination should have HSV testing and syphilis serology. Counseling and testing for HIV should also be performed, or a referral made, depending on available resources. If discharge is present, vaginal smears should be sent for yeast and bacterial testing, as well as wet mount preparation if available.
The diagnosis of pinworms can be confirmed with the “scotch tape” test, applying tape to the perianal skin and placing the tape on a glass slide where eggs may be visualized on microscopy.
Routine blood work such as a complete blood count, metabolic panel, or blood culture, is rarely indicated.
KEY TESTING
• Urinalysis and urine culture
• STI testing
ED MANAGEMENT
It is important for the emergency physician to address analgesia for children in pain. The family should be instructed to increase fluid intake to help dilute the urine. Consider prescribing pyridium, a bladder analgesic, for children older than 6 years. Management of dysuria is otherwise guided by the suspected etiology. For children being treated for infection, the first antibiotic dose should be administered in the ED to ensure that oral therapy will be tolerated.
If the urinalysis is positive, children should be empirically started on antibiotic therapy and confirmatory cultures sent to further guide management decisions. Hospitalization with IV antibiotics should be considered for young infants and children with clinical signs of dehydration, vomiting (especially if unable to tolerate fluids and medications orally), ill-appearing children with signs of urosepsis, or concerns about patient compliance or follow-up. Community microbial resistance patterns must be considered when making empiric antibiotic choices (see Chapter 288 for antibiotic recommendations).
The physician must establish ways to ensure follow-up of positive STI tests. Patients must also be informed that their sexual partners need to be tested and treated if needed, and that they should abstain from sexual activity until at least 1 week after they and their partners have completed treatment. Expedited partner therapy, which involves providing prescriptions for patients to give to their sexual partners without first examining them, is an option to consider. Inpatient management with intravenous antibiotics should be considered for patients who have already failed outpatient treatment, children with immunodeficiency, those with a tuboovarian abscess identified on ED evaluation, those unable to tolerate oral fluids or medications, or if there is concern for compliance or the ability to follow-up (see Chapter 184 for details on recommended management).
No specific treatment is indicated for vulvovaginitis. Anticipatory guidance is key for parents, which should include instructions on wiping from front to back, wearing cotton underwear, avoiding tight clothing, and avoiding potential irritants. Barrier emollient creams can be used to reduce irritation. Antibiotics should generally be limited to those with bacteria isolated on culture. A presumptive diagnosis of candida vaginitis can be made based on the presence of a “cottage cheese” like discharge on examination, and treated with a single dose of fluconazole 150 mg. Treatment of symptomatic labial adhesions is with topical estrogen cream twice daily until separation occurs, usually within 1 month.
Pinworms can be treated with a single dose of 100 mg of mebendazole or 400 mg of albendazole. A second dose should be repeated in 2 weeks. All household members over 2 years old should be treated. Anticipatory guidance should be given on washing, bedding, and frequent hand washing to prevent reinfection.
CRITICAL INTERVENTIONS
• All pediatric patients with a suspected infectious cause of their dysuria should be assessed for signs of dehydration or sepsis.
DISPOSITION
All neonates with UTI should be admitted to the hospital for IV antibiotics as per febrile neonate guidelines. Admission should also be considered for children who are ill appearing, have signs of dehydration, or cannot tolerate fluids or medications by mouth. Most other patients can be safely discharged home with appropriate instructions that address supportive care at home, recommendations for follow-up, and indications to return urgently for further care.
Common Pitfalls
• Failure to perform a GU examination in child presenting to the ED with dysuria.
• Making testing and treatment decisions for STI based on sexual history alone, which can be unreliable in the adolescent population.
• Failure to recognize STI in the adolescent presenting with a complaint of dysuria.
• Failure to recommend treatment for partners when treating patients for STI.
• Failure to diagnose UTI.
• Failure to recognize rare but serious systemic illnesses that may present with dysuria.
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