1 How is the diagnosis of testicular torsion made?

A torsed testis is typically swollen and tender and lies higher in the scrotum than that on the contralateral side. Erythema of the scrotal skin may or may not be present. Edema increases with time. In the case of complete torsion, the cremasteric reflex is absent. The presence of a brisk cremasteric reflex with a 2- to 3-cm testicular shift makes the diagnosis of testicular torsion very unlikely. Pain may be referred to the abdomen. Systemic symptoms (nausea, vomiting, diaphoresis) may also occur. Color Doppler ultrasonography has become the imaging study of choice. Its availability increases its value as compared with scintigraphy. No clinical findings, laboratory tests, or radiographic studies can approach the sensitivity of surgical exploration.

2 How is testicular torsion differentiated from torsion of the appendix testis?

Although it can happen at any age, torsion of the appendix testis is most common from ages 7 through 12 years. Pain in torsion of the appendix testis is reportedly not as severe as that seen in testicular torsion. Classically, the blue dot sign on the scrotum indicates the site of the infarcted appendage, although as edema increases this may become obscured. In the early stages, pain may be localized initially to the upper pole of the testis, with the remainder of the testis nontender. Doppler ultrasonography reveals normal or increased blood flow to the affected testis in the case of torsion of the appendix testis, whereas arterial blood flow is absent or diminished in the case of testicular torsion. None of these studies is perfect, and changes in blood flow may be missed, especially in the case of intermittent torsion. Treatment for torsion of the torsed appendix includes analgesics or anti-inflammatory medications and rest. Pain should resolve in 2–5 days.

3 Why does epididymitis occur more frequently in adolescent males?

Epididymitis indicates the presence of inflammation of the epididymis. It generally results from infection, which may lead to an enlarged and tender epididymis on palpation. Patients may also have evidence of urinary tract infection (UTI), including dysuria and frequency. Most cases in young men are caused by sexually transmitted organisms, predominantly Chlamydia trachomatis, followed by Neisseria gonorrhoeae and Ureaplasma urealyticum. These organisms are common among adolescent boys. Patients should be treated for both chlamydia and gonorrhea. Epididymitis is extremely rare among prepubertal boys; if it is diagnosed, further investigation is warranted to rule out structural abnormalities of the urinary tract.

4 Can epididymitis be treated on an outpatient basis?

Patients who are febrile and toxic-appearing should be admitted to the hospital for treatment with IV antibiotics, and possibly for further diagnostic tests to exclude a scrotal or testicular abscess (e.g., testicular ultrasonography). Otherwise, outpatient therapy is appropriate. Treatment for sexually transmitted disease–related epididymitis includes a single dose of ceftriaxone, 250 mg intramuscularly, and doxycycline, 100 mg orally twice daily for 7–10 days. Also evaluate and treat the patient’s sexual partner(s).

5 Describe the difference between phimosis and paraphimosis

Both of these conditions are seen in the uncircumcised male. Phimosis occurs when the distal foreskin is too tight to retract over the glans penis. Paraphimosis occurs when the foreskin is left in the retracted position, becomes swollen and edematous, and is then unable to be reduced (Fig. 49-1). Phimosis is not generally a problem in children, and is normal in boys younger than 6 months. Frequent retraction of the foreskin should not routinely be attempted in infants. In contrast, paraphimosis should be reduced. This is generally accomplished by application of lidocaine gel to the swollen foreskin, followed by steady pressure on the glans. Then pull the foreskin forward while pushing the glans backward with the thumb, as you would to turn a sock inside out. A dorsal penile block with local anesthetic may make the patient more comfortable, but it is generally not needed.

Figure 49-1 Paraphimosis. (Photo by John Lorselle, MD, with permission.)

6 What is balanoposthitis?

Balanoposthitis occurs in uncircumcised boys. It is an infection of the foreskin that may also affect the glans. If the foreskin is irritated as the result of poor hygiene, a break in the skin may occur, allowing bacteria to establish cellulitis. Treatment includes warm soaks and oral antibiotics (amoxicillin). Voiding may be more comfortable while the patient is sitting in a tub of warm water. True phimosis may occur as a complication, resulting from scarring after the inflammatory reaction. Circumcision may be necessary to avoid recurrent infections. The term balanitis is used to describe an infection involving only the glans penis.

7 What are other causes of penile swelling in children?

Penile swelling is usually painful and results from infection, sickling of red blood cells, or trauma. Other considerations in the presence of isolated, nontender penile swelling include insect bite (look for the lesion), allergic reaction, or more generalized edematous states, including renal, cardiac, or hepatic problems.

8 How do a “communicating” and a “noncommunicating” hydrocele differ?

A hydrocele is an accumulation of fluid within the tunica vaginalis surrounding the testis. Although it may arise in the case of torsion, trauma, tumor, or epididymitis, a simple hydrocele may be present in the absence of any underlying testicular abnormality. Infants may be left with a simple noncommunicating hydrocele when fluid is trapped around the testis after the processus vaginalis has closed during development. The baby presents with painless scrotal swelling of constant size. Management consists of observation only, as most are resorbed by the age of 12–18 months.

If the history is of scrotal swelling that “comes and goes,” especially with crying or exertion, the same fluid may be present, but the processus vaginalis has not closed. This allows “communication” between the scrotum and the abdominal cavity. Treatment in this case is surgical exploration with ligation of the processus vaginalis and drainage of the hydrocele.

Brenner J, Ojo A: Causes of painless scrotal swelling in children and adolescents: www.uptodate.com

9 In an infant, how can a hydrocele be differentiated from an inguinal hernia?

The history given with an inguinal hernia is generally that the parents have observed a nonpainful, nonerythematous scrotal and inguinal swelling in males, or inguinal swelling in females. The swelling typically occurs when the baby is crying or straining. Sometimes bowel sounds can be heard over the mass. In contrast, the swelling of a hydrocele, though it may extend toward the inguinal canal, should not be felt as a mass at the internal inguinal ring.

Transillumination with a high-intensity light does not definitively make the distinction. Although the mass of a hydrocele generally does transilluminate, transillumination of a hernia can be variable.

10 What should be done to reduce an inguinal hernia?

First determine that the testes are bilaterally descended. Apply steady, gentle pressure to the mass in the direction of the inguinal ring. Often the mass will slip easily back into the abdominal cavity. It may take several minutes of steady pressure to accomplish this goal. If the hernia remains difficult to reduce, it may be necessary to sedate the child (e.g., with midazolam), and place him or her in the Trendelenburg position. This may be enough to allow the child to relax and the hernia to reduce.

11 What is a ureterocoele?

A ureterocele is a dilation of the distal ureter that produces a cystic structure within the bladder. Ureteroceles can prolapse out of the bladder neck, and in doing so may cause bladder outlet obstruction. In a female, a ball valving ureterocele is the most common cause of bladder outlet obstruction. These patients will present with a painless pink cystic structure that is bulging out between the labia. This may be reduced by placing a feeding tube within the bladder. Ureteroceles should be managed by urologists, who will usually opt to carry out an endoscopic puncture and decompression of the obstructed system.

12 How can one distinguish between a prolapsed ureterocoele and a prolapsed urethra?

The differentiation of a prolapsed ureterocele and urethral prolapse can usually be made by physical examination. A urethral prolapse appears as a red or purplish doughnut-shaped mass. It is usually not tender and is 1–2 cm in diameter. A small central dimple indicates the lumen of the urethra. Rarely, there may be a dark ring of necrotic tissue around the edge of the prolapse. In contrast, the prolapsed ureterocele is a cystic swelling of the terminal ureter and appears as a cystic mass protruding from the urethra. They are frequently associated with ureteral duplication.

13 What is the most common cause of severe obstructive uropathy in children?

Posterior urethral valves is most common and occurs only in boys. If the condition is not diagnosed in utero, the infant presents with a palpably distended bladder and a weak urinary stream. Urgent urologic consultation is indicated.

14 What is the first evaluation to do for a patient with “blood in the urine”?

Confirm that the red urine actually contains blood. Urine can appear red as the result of ingestion of a number of foods (blackberries, beets, red Kool-Aid drink, Fruit Loops cereal), substances (aniline dyes, urates), or drugs (phenazopyridine, phenolphthalein). A urine dipstick test can quickly and easily determine whether blood is present. If the result is positive, send the urine for microscopic analysis to determine the presence or absence of red blood cells. Myoglobin will also give a positive result for blood on the dipstick. The presence of > 5–10 red blood cells/high-powered field should be considered hematuria, often warranting further work-up.

15 Describe the differences among bacteriuria, cystitis, pyelonephritis, and urethritis

Bacteriuria refers to the presence of bacteria anywhere in the urinary tract. It may or may not cause symptoms.

Cystitis and pyelonephritis are part of the continuum of UTIs. Cystitis is bacteriuria with invasion of the bladder mucosa. Patients with cystitis present with urgency, frequency, and dysuria, and may on occasion develop a low-grade fever.

Pyelonephritis occurs when the UTI has localized within the renal parenchyma and causes systemic symptoms; thus, it is the most serious of UTIs. Children present with fever (temperature often > 39° C) pyuria, and bacteruria, often accompanied by nausea, vomiting, leukocytosis, flank pain, and tenderness.

Urethritis indicates inflammation or an infection localized to the urethra. There is usually a discharge, and in adolescents, urethritis generally is a manifestation of a sexually transmitted disease (C. trachomatis or N. gonorrhoeae infection). Urethritis can also result from noninfectious causes, including local irritation from detergents, fabric softeners, soaps, or bubble baths, as well as minor injury.

16 What are the most common organisms in UTI?

Most common are the enteric organisms, with Escherichia coli isolated in about 90% of cases. Other less common organisms include Enterobacter, Klebsiella, and Proteus spp. Enterococcus sp. occasionally is isolated in patients of any age. Staphylococcus saprophyticus and Staphylococcus epidermidis are seen in adolescents, while group B streptococci are found in infants and during pregnancy. In immunocompromised and chronically ill patients, as well as patients with anatomic abnormalities or indwelling catheters, Pseudomonas aeruginosa, C. albicans, and Staphylococcus aureus account for a small percentage of UTIs.

17 Which age groups most commonly get UTIs?

Overall, UTIs are more common in neonates and infants and in sexually active adolescent females. As many as 3–5% of febrile young infants presenting to the emergency department (ED) have a UTI. In neonates and infants under the age of 6 months, males have a higher incidence, perhaps because of a higher incidence of anomalies of the urinary tract. After this age, UTI becomes less common in males and is rare beyond the age of 1 year. In contrast, girls have a rate of UTI as much as tenfold higher than that of boys between the ages of 6 months and 2 years, with the risk being greater in the first year than in the second.

18 List the variables that have optimal diagnostic accuracy in diagnosing UTI in young females

Note: Three or more of the above have the best accuracy in making the diagnosis.

Gorelick MH, Hoberman A, Kearney D, et al: Validation of a decision rule identifying febrile young girls at high risk for urinary tract infection. Pediatr Emerg Care 19:162, 2003.

19 How does the clinical presentation of UTI vary with the age of the patient?

Neonates and very young infants with UTI may present with fever or with nonspecific symptoms, including poor feeding, vomiting, diarrhea, irritability, jaundice, and even seizures. This is clearly why assessment of the urine is an integral part of the “full sepsis work up” performed on infants with any of these presenting symptoms.

Older infants and children up to the age of 2 years often have fever, and parents may notice such urinary symptoms as change in voiding pattern or foul-smelling urine. Preschool and school-age children describe specific urologic symptoms, such as frequency, urgency, dysuria, and enuresis. They may also report less specific symptoms, including abdominal pain and vomiting.

20 When should I get a catheterized specimen as opposed to a “clean-catch” specimen?

The external genitalia should be examined for signs of inflammation or infection. Obtain a catheterized specimen (or in some instances a specimen by suprapubic tap) in any patient who lacks bladder control (e.g., infants and toddlers), has evidence of vaginitis, or is unable to provide an adequate midstream specimen. Putting a urine “bag” on any infant or toddler is not helpful if the specimen is being collected for culture because the urine will probably be contaminated with perineal flora, no matter how much preparation is done. This type of collection is reliable only if the culture has no growth. If you suspect that a child has a UTI, it is worth getting the most accurate specimen possible.

21 What is the significance of a positive test result for nitrites on the urine dipstick?

Most urinary pathogens (with the exception of enterococcus) are able to reduce urine nitrates to nitrite. Hence, a positive test result indicates the presence of pathogenic bacteria.

22 What is the significiance of a positive leukocyte esterase test result?

Leukocytes are able to convert indoxyl carboxylic acid to an indoxyl moiety. This test is highly specific for pyuria.

23 How should dipstick indicators be used to screen for UTI?

Many studies have been published regarding the usefulness of these tests in diagnosing UTI. Most of the studies have been performed in adult patients, and results of studies in children frequently differ. A meta-analysis by Gorelick and Shaw concludes that the presence of nitrites or leukocyte esterase or both on a dipstick test is almost as sensitive as a Gram stain in detecting UTI in children.

Gorelick MH, Shaw KN: Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 104:e54, 1999.

24 Do white blood cells in the urine always signify a UTI?

No, not always. Pyuria can be found in the absence of bacteriuria (i.e., “sterile pyuria”). Vaginitis can cause the leukocyte esterase test result to be positive, but does not necessarily mean the patient has a UTI. Moreover, an inflammatory process in the abdomen (e.g., appendicitis, inflammatory bowel disease, pelvic inflammatory disease) can cause white blood cells to appear in the urine. A recent meta-analysis shows that the presence of white blood cells in the urine (either spun or unspun) is only about 75% sensitive for UTI.

25 Is a gram stain of the urine helpful?

The presence of any bacteria on Gram stain of an uncentrifuged urine specimen is about 93% sensitive for detection of UTI, compared with culture as the reference standard. It does, however, require trained personnel to prepare the sample and read the results, and may not be available to the emergency physician at all times. Fortunately, dipstick analysis has been shown to be almost as sensitive in detecting UTI and is a readily available, quick, easy, and inexpensive alternative.

Gorelick MH, Shaw KN: Screening tests for urinary tract infection in children: A meta-analysis. Pediatrics 104:e54, 1999.

26 When should you order a urine culture?

Opinions differ, and there are no clear-cut answers to this question. Practice parameters developed by the American Academy of Pediatrics (AAP) in 1999 recommend culture for infants and young children 2 months to 2 years of age with unexplained fever. An evidence-based review of the recent literature suggests that for children younger than 36 months of age who present with fever without source or UTI symptoms (e.g., dysuria, vomiting, abdominal pain), a urine culture should be obtained by using an age-appropriate method. If the child is 3 years of age or older, a culture should be sent if the urine dipstick result is positive for nitrite or leukocyte esterase, or if the patient is symptomatic (even with a negative dipstick result).

27 Which patients should be treated with antibiotics?

Patients of any age should be treated presumptively if the dipstick result is positive for moderate leukocyte esterase or nitrite, if they have symptoms of UTI, or if follow-up is in question. For patients with a negative dipstick result (or trace leukocyte esterase but otherwise negative results), no symptoms other than fever, and good follow-up, it is prudent to defer treatment while awaiting results of culture. Febrile infants younger than 1 month of age should be treated empirically with antibiotics because of the risk of serious bacterial illness. Infants 1–2 months of age should undergo thorough evaluation and be treated if there is evidence of UTI.

28 What should be the duration of treatment for UTI?

A 10-day course is recommended for antibiotic therapy in children. High failure rates have been documented for shorter courses of treatment.

29 Which patients with UTI should be admitted for parenteral antibiotics?

AAP Practice Parameters recommend parenteral therapy for infants and young children with suspected UTI who are “toxic, dehydrated, or unable to retain oral intake.” Those who “may not appear ill but who have a culture confirming the presence of UTI” should have antimicrobial therapy initiated either parenterally or orally. Additional considerations in the decision to admit a patient include the presence of underlying urologic abnormalities, identification of a urinary pathogen resistant to oral antibiotics, and issues regarding adherence with outpatient therapy. Indication for parenteral therapy based on patient age varies in the literature, with some authors recommending IV antibiotics for patients younger than 3 to 6 months of age, and some extending the recommendation to 1 year of age.

Hoberman A, Wald ER: Treatment of urinary tract infections. Pediatr Infect Dis J 18:1020–1021, 1999.

American Academy of Pediatrics: www.aap.org

30 Define urinary retention

Urinary retention is the inability to pass urine from the bladder through the urethra. Since urine is being produced normally, the bladder may become largely distended, causing substantial discomfort to the patient.

31 What causes urinary retention in infants?

In the infant, most urinary retention is the result of obstruction. In males, the most common cause is posterior urethral valves; other causes include urethral polyps, strictures, diverticula, and, rarely, meatal stenosis. Urinary retention has been noted as a complication of the Plastibell device used for circumcision. Female infants may experience a prolapsing ureterocele, urethral prolapse, or a foreign body. Neurologic urinary retention may result from a spinal cord lesion.

32 How can sexual abuse contribute to urinary retention?

The emergency physician should always be aware that urinary retention or dysfunctional voiding may on rare occasions be the presenting symptom of sexual abuse. Children who have been sexually abused are often very fearful of any processes involving the genitalia, and seek to avoid that portion of their anatomy. Furthermore, abusive acts may result in genital or urethral trauma or infection. Ask appropriate questions if no other cause for urinary retention can be found.

33 What should be done in the ED about urinary retention?

The approach depends on the cause. Refer newborn infants with ineffective voiding to a urologist for further evaluation. While waiting for the consultant, obtain a basic metabolic panel to check electrolytes, blood urea nitrogen (BUN), and creatinine. A suprapubic tap may be necessary to obtain a specimen for urinalysis. Consult a neurologist if a spinal cord lesion is suspected on the basis of physical examination. Older children who have previously voided normally may be catheterized for urinalysis if they are unable to void. Treat infections with appropriate antibiotics. Retention from trauma to the urethra should be treated with frequent sitz baths (at least three times per day). Medications causing retention should be discontinued if possible. Urinary retention suspected to be of psychosomatic origin or as the result of sexual abuse should be referred to psychiatric and sexual abuse management specialists as appropriate. If the patient is unable to void, catheterization may be necessary.

34 What causes renal stones in children?

Renal stones (calculi) are uncommon in children and adolescents. Seven percent of urinary calculi occur in children younger than 16 years of age. The cause of calculi depends on geography. In the United States, most stones are attributed to metabolic causes, and most contain calcium. Infectious stones are more common in European children, and uric acid stones occur in southeast Asian children. Boys and girls are equally likely to be affected, and 94% of stones occur in white persons.

Cronan K, Kost S: Renal emergencies. In Fleisher G, Ludwig S, Henretig F (eds). Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 913–914.

35 What are the symptoms of urolithiasis in children?

Unlike the classic presentation of excruciating abdominal pain seen in adults, symptoms in children can be far less specific. The patient may appear uncomfortable and may report flank pain, abdominal pain, or costovertebral angle tenderness. Intense pain may cause an elevation in heart rate and blood pressure. Almost all children have some degree of hematuria, which may be microscopic or macroscopic. They may also have symptoms of dysuria, urinary frequency, or urinary retention. The etiology of these symptoms needs to be distinguished from UTI.

36 How is the diagnosis of urolithiasis confirmed?

The first test to obtain is a urinalysis, to look for hematuria and for crystals in the urinary sediment. In recent years, spiral computed tomography has become the accepted gold standard study for the detection of urolithiasis, albeit at the expense of a higher dose of radiation exposure.

37 What treatment for urolithiasis should be initiated in the ED?

The foremost issue that must be addressed in the ED is pain management. Nonsteroidal anti-inflammatory drugs may be adequate if the patient is able to tolerate oral intake, but IV ketorolac offers excellent pain relief and may reduce the need for narcotics. Obtain urologic consultation in any patient with evidence of obstruction since endoscopic stenting may be indicated. Initiate IV hydration and strain the urine to collect any particles for laboratory analysis. Prescribe antibiotics if there is an associated UTI.

38 Which patients with urolithiasis need to be admitted?

Any patient with evidence of obstruction should be admitted with urologic consultation, since immediate intervention (e.g., endoscopic stenting or ureteroscopy with stone extraction) is necessary to relieve the obstructing stone. Also consider admission for patients with severe pain requiring parenteral analgesia, vomiting or dehydration, and inability to tolerate oral hydration. Patients with renal insufficiency, structural abnormalities of the genitourinary tract, or a solitary kidney should also be admitted.

Bartosh S: Medical management of pediatric stone disease. Urol Clin North Am 31: 575–588, 2004.

39 What are the presenting symptoms of uretero pelvic junction obstruction in older children?

Uretero pelvic junction obstruction presents more commonly on the left side and is bilateral in 10% of cases. The male-to-female ratio is 2:1. There is a history of episodic pain that can occur in the abdomen, flank, or back. Nausea and vomiting may occur. The episodes of pain last from 30 minutes to several hours. Examination may reveal an enlarged kidney and tenderness.

40 What is the most common cause of acute glomerulonephritis?

There are numerous causes of acute glomerulonephritis, but in children the most common is postinfectious or poststreptococcal nephritis. It is a syndrome that occurs predominantly in school-aged children, and is characterized by the sudden appearance of either grossly bloody or tea-colored urine, peripheral edema, and decreased urine output. Patients generally present 1–2 weeks after having had a sore throat, sometimes 2–3 weeks after a case of impetigo. Other infectious causes include viral upper respiratory tract infections or mononucleosis syndromes.

41 What are the physical findings in acute glomerulonephritis?

In addition to dark or bloody urine, peripheral edema develops. The edema is firm, and initially appears around the eyes. Weight gain is frequently noted. Patients may have mildly elevated blood pressure. Some children have no symptoms other than abnormally colored urine. In others, hypertension can be significant and lead to complications requiring emergency intervention.

42 What laboratory tests should I order for suspected acute glomerulonephritis?

The most important test is the urinalysis, with a microscopic examination of the urine. Dysmorphic red blood cells and red blood cell casts are diagnostic of this condition. Significant proteinuria is also characteristic. White blood cells may be present, and since hematuria and proteinuria may be presenting signs of a UTI, a urine culture should be included in the initial evaluation. Other studies include complete blood count with differential, platelet count, erythrocyte sedimentation rate, serum electrolytes, calcium, BUN, creatinine, total protein, albumin, and complement (C3 and C4). Antistreptolysin O titer should be tested if poststreptococcal acute glomerulonephritis is considered; antinuclear antibody and anti–double-stranded DNA should be done in the case of systemic lupus erythematosus. Order prothrombin time and partial thromboplastin time if there is concern about a bleeding diathesis. A throat culture may reveal group A streptococcal infection, and chest radiography may be important to evaluate heart size in a hypertensive patient.

43 What are the goals of ED management of acute glomerulonephritis?

The goal is aggressive treatment of life-threatening complications, particularly hypertension, congestive heart failure (CHF), and hyperkalemia. If the blood pressure is elevated but the patient is asymptomatic, oral antihypertensives (sublingual nifedipine or captopril) may be adequate. In the patient with acute neurologic changes, antihypertensives (diazoxide or hydralazine) should be given intravenously. Treat CHF by keeping the head of the bed elevated, providing supplemental oxygen, and promoting diuresis with furosemide (0.5–1.0 mg/kg via IV route). Tailor fluid management to restrict volume and sodium, to replace only insensible losses plus urine output. Do not give potassium until the patient’s urine output is established and hyperkalemia is resolved.

44 What is the most common cause of nephrotic syndrome in children?

Nephrotic syndrome is a constellation of findings, including edema, proteinuria, hypoalbuminemia, and hyperlipidemia. It can occur in children as a primary renal disorder, or secondary to systemic disease, environmental toxins (heavy metals, bee venom), or medications. About 80% of pediatric cases occur between the ages of 2 and 5 years and are associated with “minimal change” or “nil disease” when renal biopsy specimens are examined.

45 How is the diagnosis of nephrotic syndrome made?

After physical examination, evaluate urine for the presence of protein. Measure total serum protein, albumin, and cholesterol levels. Typical values in nephrotic syndrome are a urinary protein of 3–4+ on dipstick, serum albumin level < 3 g/dL, and elevated cholesterol level. Other laboratory values that may be important for management include the hematocrit (which may be elevated secondary to intravascular volume depletion), electrolytes (sodium is often low); and BUN/creatinine (BUN level may initially be elevated, reflecting the lowered intravascular volume; creatinine level may be normal or elevated depending on whether there is primary renal damage).

46 What management decisions need to be made in the ED for a child with nephrotic syndrome?

Complications requiring emergency management include the progression from hypovolemia to shock, hypercoagulability, and pleural effusions and ascites leading to difficulty walking, abdominal pain, or respiratory distress. The child must be evaluated for peritonitis, usually due to Streptococcus pneumoniae. Give normal saline boluses (20 mL/kg) to restore circulation, if needed. For symptomatic massive edema, furosemide can be given orally, or in extreme cases, albumin followed by IV furosemide. Rarely is paracentesis necessary. Deep venipunctures should be avoided because of the increased risk of thromboembolic events.

47 What is the treatment for nephrotic syndrome?

Steroids (prednisone) at 2 mg/kg/d. Start antibiotics (after blood culture is obtained) if the child is febrile or there is another reason to suspect bacterial infection.

48 Should all patients with nephrotic syndrome be admitted?

Most should be, including those newly diagnosed, those in whom there is a possibility of infection, and any who are symptomatic from dehydration or edema. Consult a pediatric nephrologist regarding steroid therapy and indications for renal biopsy.

49 What is the treatment for priapism?

Priapism (prolonged painful penile erection without sexual stimulation) may be caused by trauma or leukemic infiltration. However, most commonly it is seen in males with sickle cell disease. Erythrocyte sickling leads to sludging in the erectile portion of the corporal bodies. Stasis yields hypoxia and more sickling occurs. The most effective treatment consists of hydration and irrigation of the corporal bodies using saline with vasoactive substances. Transfusion of packed red blood cells is reserved for refractory cases. Urologic consultation should be obtained.