Paediatric Urology and Gynaecology

Normal penis and foreskin

• Non-retractile foreskin at birth
  • 40% at 1 year
  • 90% at 4 years
  • 99% at 15 years
• Minor inflammation (posthitis
  • Irritation, inappropriate attempts at retraction, bubble bath, soap residue
  • Napkin barrier cream is usually enough
  • Hydrocortisone 1% cream or ointment may help

Balanitis

• Balanitis
  • Often due to infection
  • 6% of uncircumcised and 3% of circumcised boys
  • Soak in warm bath with foreskin retracted
  • 1% hydrocortisone may help
  • Candida may be responsible in some, usually with more generalised nappy candidiasis and satellite lesions
  • Topical antibiotics are of unproven benefit
• Bacterial infection
  • If significant cellulitis of whole foreskin or shaft skin then needs antibiotics
  • Swabbing is not useful due to normal flora
  • Most cases respond to bactrim or amoxicillin
  • Analgesia and sitting in warm bath can help urination
  • Rarely urgent surgery for dorsal slit or circumcision is required

Zipper injury

• Liberal topical anaesthetic OR local infiltration will be required (NEVER WITH ADRENALINE)
• Dorsal nerve block may be useful
• If trapped between teeth below the slider:
  • Cut median bar of zipper with wire cutters (holds front and back of zip together)
  • Alternatively, cut material either side of zipper below where entrapment has occurred and then cut across zipper with wire cutters
  • Can then pull zipper apart easily
• If trapped between slider and teeth of zipper
  • Ease slider down after adequate analgesia and then check for injury

Phimosis

• True phimosis = scar tissue present at distal foreskin preventing retraction
• May result from forcible retraction attempts when not ready
• Indicators of true phimosis
  • Foreskin not retractile by established puberty
  • Previously retractile foreskin no longer retractile
  • Obvious ring of scar
  • Inability to visualise urethral meatus
  • Ballooning of foreskin with micturition and very narrow urine stream
• Treatment
  • Topical steroid creams 0.05% betamethasone BD for 2-4 weeks
  • Gently retract as far as comfortable and apply thick cream at tightest part
  • Circumcision

Paraphimosis

• Foreskin left in retracted position with oedema of distal glans
• Adequate analgesia/sedation
  • Cover liberally with topical anaesthetic and glad wrap for 1 hour
  • Avoid infiltration of anaesthetic as worsens swelling
  • Swollen area compressed with one hand and glans pushed back after compression
  • May require nitrous/fentanyl
  • Two thumb technique involves both thumbs over glans and fingers pulling foreskin back over
  • Consult surgery if fails
• Hair tourniquet
  • Consider if presents with distal redness and swelling

Circumcision

• <10% of newborns now
• Advised against if <6mo
• Medical indications
  • Significant phimosis despite steroid therapy
• Post-circumcision issues
  • Bleeding site can be a sign of coagulopathy. FBC and coags should be checked
  • Treat as for cellulitis elsewhere
  • Infants <1mo should be admitted for IV Ab’s

Pre-pubescent gynaecology

• Vaginal discharge
• Vulvovaginitis
• Vaginal bleeding

Vaginal discharge

• Physiological
  • White mucoid discharge normal in neonates due to maternal oestrogens
    • Disappears by 3mo
  • At onset of puberty may get physiological discharge
• Consider
  • Vulvovaginitis
  • Lichen sclerosis
  • Foreign body
  • Eczema
  • Pinworms

Vulvovaginitis

• Most common gynaecological problem in childhood
• More commonly a cause for dysuria than UTI
• Mostly irritation vs. infection
• Infectious indicated by profuse discharge with marked skin inflammation, often beyond margin of labia
• Usually GAS, Staph, Enterococci or E. coli
• Identification of N. gonorrhoea or C. trachomatis generally indicates sexual abuse
• Management
  • Avoid potential soap irritants, tight/synthetic clothing, wet togs
  • Vinegar in bath
  • Simple barrier cream to area

Lichen sclerosis

• Vulval irritation, pruritis, dysuria or bleeding
• Pale atrophic patches on labia and perineum
• Patches can be extensive and coalesce with chronic inflammatory changes
• Most resolve before puberty
• Treatment
  • As for vulvovaginitis
  • Consider brief course of topical 1% hydrocortisone and referral if ongoing issues

Eczema

• Vulvovaginitis + Itch
• Usually eczema elsewhere indicates this
• Treat as for eczema elsewhere with mild steroids

Candida

• Very uncommon in prepubertal girls unless recent antibiotic use or still in nappies
• Recurrent or unexplained candida requires Ix for diabetes or other immunmosuppression

Pinworms

• Consider if dominant itch symptoms
• Test with clear sticky tape in morning and microscopy
• Perianal excoriation suggestive
• Treatment
  • Pyrantel or mebendazole

Foreign body

• If considered (often bloody purulent discharge) examination under anaesthesia required
• USS may help if not sure

Vaginal bleeding

• Normal up to 3-4 weeks
• Hormonal
  • Neonates (withdrawal bleed due to maternal oestrogens)
  • Onset of menstruation (precocious if <8yo)
• Non-hormonal
  • Vulvovaginitis (consider Shigella or Group A beta-haemolytic streptococci)
  • Trauma (consider NAI)
  • Foreign body (consider if no other cause for vulvovaginitis evident)
  • Tumours (consider if chronic ulceration, genital enlargement/tissue/swelling
  • Bleeding disorders
  • Non-vaginal e.g. urethral prolapse or haematuria

Who needs examination under anaesthesia?

• Penetrating trauma, persistent bleeding, uncertain origin of bleeding, massive bruising or likely FB

Labial adhesions

• Due to secondary atrophic mucosa adhering to one another
• No treatment necessary and resolves with menarche
  • If unable to void, consider topical oestrogen cream or division with lateral traction in concert with paediatric urology

Distressing vaginal pain

• Reported in young girls with pinworms who have severe pain when worms crawl onto thin atrophic hymen
• Treatment with mebendazole indicated

Vaginal discharge in adolescents

• DDx
  • Physiological
  • Candida
  • Bacterial vaginosis: Homogenous white discharge with fishy odour
  • Trichomoniasis: Frothy, green vaginal discharge. Sexually transmitted.
  • Chlamydia and gonorrhoea +- PID
  • Retained tampon

Abnormal vaginal bleeding

• Anovulatory bleeding can continue for 5 years post-menarche as HPA axis matures
• 20% of patients admitted will have underlying coagulopathy
  • 50% of these have vonWillebrand’s disease and other half mostly due to platelet dysfunction
• FBC, iron studies and coagulopathy indicated
• Pregnancy test
• Consider STI screening
• Consider USS
• Treatment
  • TXA
  • Progesterone and/or oestrogen therapy

Last Updated on November 9, 2021 by Andrew Crofton