ACUTE URINARY RETENTION IN CHILDREN

Acute urinary retention in children: causes and the role of bladder catheterization and ultrasonogram

BACKGROUND

Acute urinary retention in children is uncommon and can be related to several causes. The role of abdominal ultrasound and catheterization is controversial. We aimed to identify the most common causes of acute urinary retention in children, focusing, particularly on the role of bladder catheterization and the diagnostic value of acute ultrasound.

METHODS

We retrospectively analyzed all consecutive children admitted to our emergency department with acute urinary retention from 2010 to 2020. Post-operative acute urinary retention, neonatal age, and known urological or neurological disorders were excluded. Diagnostic workup and management were adopted in each patient. Results were compared in patients with more and less than 5 years old.

RESULTS

193 patients were included. Median age was 3 (2-16) years; 53.4% were girls. Ultrasound evaluation was performed in (129/193; 66.8%) patients, more commonly <5-year-old (74% vs. 26%, P<0.01). A previously unknown urological condition was detected in (16/129; 12%). The majority of patients (124/193; 64%) were managed without bladder catheterization. These patients were significantly younger than the remainder (3- vs. 4-year-old, P<0.01) and the most common diagnosis was external genitalia inflammation (53%). Of the remaining patients, (34/69; 49%) restored spontaneous micturition after a single catheterization, whereas 35 required admission. The latter were more commonly males (32%, P=0.01), with higher incidence of abnormal ultrasound (33% vs. 7%, P<0.001).

CONCLUSIONS

Acute urinary retention in commonly due to external genitalia inflammation, particularly in patients <5-year-old, and can be generally managed, without bladder catheterization. Abdominal ultrasound is an important diagnostic tool, that should be performed only in selected cases.

Clinical Toxicology of OTC Cough and Cold Pediatric Medications: A Narrative Review

Cough and cold symptoms (CCS) are common pediatric conditions often treated with over-the-counter (OTC) medications. However, the available knowledge regarding the safety and toxicity of these medications in children is inadequate. Therefore, understanding their clinical toxicology is crucial for safeguarding children's well-being. This narrative review highlights the importance of clinical toxicology in evaluating the safety and toxicity profile of OTC medications for treating CCS in pediatric patients. The pharmacology, clinical features, and adverse effects of various drug classes commonly found in cough and cold medications are briefly discussed. Pharmacokinetic and pharmacodynamic parameters are also examined to understand the interactions between these drugs and the body. OTC cough and cold medications often contain active ingredients such as antihistamines, decongestants, antitussives, expectorants, and analgesics-antipyretics. The combination of multiple ingredients in these products significantly increases the risk of adverse effects and unintentional overdoses. Several case studies have reported significant toxicity and even fatalities associated with the use of these medications in children. This review underscores the critical importance of clinical toxicology in evaluating the safety and toxicity profile of OTC medications employed for treating CCS in pediatric patients. The findings highlight the significance of informed clinical practice and public health policies to ensure the well-being of children using OTC cough and cold medications.

Three rare etiologies of urinary retention in pediatrics: A case series and review of the literature

Etiology of urinary retention in pediatric age differs significantly from adults and the elderly. Therefore, a comprehensive diagnosis is crucial before specific treatment. Every effort must be made to minimize invasive procedures as far as possible in children.

Urinary bladder retention secondary to intranasal administration of oxymetazoline "Afrin" for intra-arterial chemotherapy

Selective ophthalmic artery infusion of chemotherapy (SOAIC) has emerged as the standard of care for retinoblastoma (RB). Intranasal oxymetazoline (INO), Afrin, is often intraoperatively administered adjunctively to optimize flow to the orbit. There has been one report to date that suggests the adjunctive use of INO has led to systemic side effects. To our knowledge, this is the first documented case of INO causing urinary retention in a patient undergoing SOAIC, and the recommended treatment.

Methylnaltrexone in the Management of Opioid-Associated Urinary Retention in Children

OBJECTIVE

To evaluate the association between methylnaltrexone and urine output (UOP) in critically ill children with opioid-associated urinary retention.

METHODS

This retrospective study included patients admitted to the pediatric intensive care unit between December 1, 2019, and November 30, 2020, who received methylnaltrexone for opioid-associated oliguria (spontaneous UOP below 1 mL/kg/hr and at least 1 dose of an opioid within the preceding 6 hours).

RESULTS

Twenty-five patients (median age = 5.5 years, IQR 1.7–16.4; median weight = 19 kg, IQR 9–45) were included. Mean methylnaltrexone dose was 0.15 ± 0.006 mg/kg. A statistically significant increase in UOP from baseline to 6 hours following methylnaltrexone was observed (p = 0.001), but not all patients responded. Fourteen patients (56%) had no UOP following methylnaltrexone administration, while 11 (44%) demonstrated a robust increase (median = 0 mL/kg/hr at baseline [IQR 0–0] to 1.96 mL/kg/hr [IQR 1.08–2.22; p = 0.001]) within 6 hours following methylnaltrexone administration. Younger patients responded better than older patients (responder age = 2.5 years [IQR 0.8–7]) versus 11.4 years [IQR 1.75–17.5] for non-responders) (p = 0.04). Both intravenous (IV) and subcutaneous (SQ) routes were associated with an increase in UOP (IV, p = 0.04; SQ, p = 0.02). The effect persisted for up to 24 hours after administration. Sixty-four percent of patients required urinary catheter placement. Pain scores (averaged 6 hours before and after methylnaltrexone) remained unchanged (p = 0.44).

CONCLUSIONS

Methylnaltrexone may increase spontaneous UOP in some children with opioid-associated urinary retention, but urinary catheterization rates remain high.

Acute urinary retention in pediatric cerebral palsy: Is there an optimal management strategy?

INTRODUCTION AND OBJECTIVE

Cerebral palsy (CP) patients commonly have lower urinary tract dysfunction. Urinary retention (UR), which has been associated with dysfunctional voiding in CP can correlate to chronic upper tract dysfunction. We sought to provide insight into the pediatric presentation of acute UR in patients with CP and subsequent outcomes in this at-risk population.

STUDY DESIGN

All children with perinatally acquired CP presenting to a regional health network were identified from 2009 to 2019. Retrospective analysis of a hospitalized subset concurrently diagnosed with a first episode of acute UR was performed. Factors associated with new-onset UR are described, as well as management. Using follow-up data, we also assessed the risk for recurrent UR and/or abnormal renal imaging after an initial UR presentation.

RESULTS

3404 CP patients were analyzed with only 33 fulfilling inclusion criteria. Median age was 10(IQR 7.5-16; range 1-22) years, 87.9% were GMFCS-V. 39.4% had a reported history of decreased urinary frequency. At presentation, median maximal time without void prior to catheterization was 13 h, and catheterized volume was a median 120% expected capacity-for-age. 84.8% of presentations were associated with a known transient/reversible etiology. 51.5% were post-anesthesia at median 3.5 days, 33.3% had associated constipation, 30.3% had received exacerbating medications. 11/33 were taught clean intermittent catheterization (CIC) after the initial presentation (all pro re nata [PRN] except one). At a median follow-up of 37 months: 50% of those without a CIC PRN no void plan had a repeat episode, at a median of 10.8 months later. Of the patients who had follow-up renal imaging at a median 22.0 months after presentation, 45% had abnormalities: 7 with debris or suspected stones and 2 with collecting system dilation. No factors associated with the initial UR presentation were found to be significantly predictive of recurrence or abnormal follow-up imaging.

DISCUSSION

Patients with CP presenting with acute UR are often those with the most severe limitations and have a history of decreased urinary frequency. They usually have transient or reversible factors associated with UR presentation, however UR recurrence and abnormal imaging in this population subset is common.

CONCLUSIONS

Pediatric patients with CP who present with acute UR usually present in the context of recent anesthesia and in the setting of exacerbating factors. They are at risk for recurrence and may be best managed with caretaker education of CIC PRN no void to address recurrent episodes. Providers should consider surveillance of these patients for the development of abnormal renal imaging.

Choosing the Right Catheter for Pediatric Procedures: Patient Considerations and Preference

Determining the need for bladder decompression and urinary diversion in the perioperative pediatric surgical patient can cause a clinical conundrum for the surgical team. Add in the several different types of urinary diversion devices possible, and the various materials associated therein and the process can suddenly seem unnecessarily daunting given the lack of concise recommendations and broad consensus. The decision to divert urine, though seemingly trivial, is associated with inherent risks. Managing and mitigating certain risks are best approached through proper education, selection, and technique. We provide a broad overview of pediatric catheter selection, indications, and pitfalls to streamline the process so that energy and attention can best be focused on the planned intervention at hand.

The importance of a thorough clinical examination in adolescent girls presenting with acute urinary retention

We present an adolescent girl with a 1-day history of acute urinary retention and lower abdominal pain. She was admitted to the paediatric ward for ongoing treatment and investigations. Due to a myriad of factors including pain and anxiety, challenges posed included an incomplete initial abdominal and external genital examination. This case report highlights the importance of a focused history and performing an appropriate sensitive examination at the time of presentation. Furthermore, we explore the common causes of new onset urinary retention and unravel the case as it unfolds. We also highlight differential diagnoses (however, uncommon), which must be considered and not overlooked to avoid unnecessary investigations and to ensure timely management.

Monitoring of micturition and bladder volumes can replace routine indwelling urinary catheters in children receiving intravenous opioids: a prospective cohort study

In this prospective observational study, the incidence, risk factors and the time to event of urinary retention in children receiving intravenous opioids were evaluated. Urinary retention was confirmed by ultrasound following the inability to void for 8 h or earlier in patients experiencing discomfort. In total, 207 opioid episodes were evaluated, of which 199 (96.1%) concerned morphine, in 187 children admitted to the pediatric ward or pediatric intensive care unit. The median age was 7.6 years (IQR 0.9-13.8), and 123 (59.4%) were male. The incidence of urinary retention was 31/207 (15.0%) opioid episodes, in which 14/32 (43.8%) patients received continuous sedation for mechanical ventilation and 17/175 (9.7%) received no sedation. Multivariable logistic regression analysis showed a significant association with continuous sedation (OR 6.8, 95% CI 2.7-17.4, p 0.001) and highest daily fluid intake (OR 0.8 per 10% deviation of normal intake, 95% CI 0.7-0.9, p 0.01). Opioid dosage, age and gender were not significantly associated. Most events (28/31, 90.3%) occurred within 24 h.Conclusion: The incidence of urinary retention in children receiving intravenous opioids is low, indicating that placement of urinary catheters is not routinely necessary in these patients. However, micturition and bladder volumes must be monitored, especially in sedated children and during the first 24 h of opioid administration. What is Known: • Great variation exists in the routine placement of urinary catheters in children receiving IV opioids. What is New: • Confirmed by ultrasound, the incidence of urinary retention in children receiving intravenous opioids in this study was 15%, indicating that placement of urinary catheters is not routinely necessary in these patients. • Children receiving continuous sedation for invasive mechanical ventilation showed a sevenfold greater risk of developing urinary retention than non-sedated patients.

Acute urinary retention in children

BACKGROUND

Acute urinary retention is a common emergency in adult patients, foremost in older men. In childhood urinary retention is a rare entity with only sparse literature on the etiology.

OBJECTIVE

To assess the etiology and treatment of acute urinary retention in the pediatric population and assess age and sex distribution.

STUDY DESIGN

A retrospective analysis of all patients admitted to our emergency department with acute urinary retention between 2005 and 2019 was performed. Exclusion criteria were newborns (because of physiologic postnatal oliguria) and postoperative urinary retention during the same hospital stay.

RESULTS

113 children with acute urinary retention (ICD: R33) meeting the above criteria were identified. 16 Patients were excluded because of incomplete medical charts. 97 children were included into the study (age 0.5-18.3 years, mean age 5.3 years). 89 patients had one episode, 8 patients two episodes. A peak around the third year of age was observed. Sex ratio showed a 2:1 male to female distribution. Most common etiology was balanoposthitis (15.5%) and acute constipation/fecal impaction (15.5%). Traumatic urinary retention was found in 11.4% of the cases. Urinary tract infection were found 7.2%. No underlying reason could be found in 12.4% (idiopathic urinary retention). Other causes included febrile non-urinary infection (8.2%), subvesical obstruction (4.1%), vulvovaginitis (3.1%) and urethritis (2.1%). In 50% of the cases of urinary retention under 1 year of age (2 out of 4) an underlying tumor (rhabdomyosarcoma, sacral teratoma) was identified.

DISCUSSION

Age and sex distribution were similar to previously published series; however, this study shows a marked difference concerning the etiology: e. g. we identified a significantly higher proportion of functional disorders as a reason for acute urinary retention in childhood. It is hypothesized that this is partly because previously published studies originate from areas (USA, Israel, Iran) with different socio-demographic and cultural background.

CONCLUSION

AUR in children is a rare condition with very heterogeneous causes. Although the majority of cases exhibit mild underlying conditions, serious reasons, such as malignant diseases especially in the first year of life, must be excluded. AUR relief without catheterization is a child-friendly approach in cases of mild inflammatory or functional disorders and can help to minimize traumatization.

Getting started in paediatric emergency medicine point-of-care ultrasound: Five fundamental applications

Point-of-care ultrasound is a valuable tool in the Paediatric Emergency Medicine department. It can be utilised at the patient bedside to augment the physical examination, improving clinical accuracy. Alternatively, it can safeguard needle guided procedures and improve their success rate. It allows real-time information to be gathered without exposing the child to ionising radiation. This article outlines five fundamental applications and how it can be incorporated into clinical practice.

Ultrasonographic Assessment of Bladder Volumes in Children Undergoing Penile Surgery: Does the Type of Anesthesia Matter?

BACKGROUND

There are scant data reporting postoperative ultrasonographically measured bladder volumes in children undergoing penile surgery.

STUDY QUESTION

We studied the effect of various anesthesia techniques on return of micturition after penile surgery in children, using ultrasonographically measured bladder volumes.

DATA SOURCES

Ultrasonographically measured postvoiding residual bladder volumes indexed to age-appropriate capacity, and time elapsed between the end of surgery and spontaneous voiding after pediatric circumcision, distal hypospadias repair, or repair of urethrocutaneous fistula, were studied.

STUDY DESIGN

Children between 4 months and 12 years were randomized to caudal block, intravenous (IV) fentanyl or penile block, in association with inhaled general anesthesia. Bladder volumes were measured before surgery and immediately after voiding for the first time. Time to first postsurgery void was also recorded.

RESULTS

Thirty-one children completed all assessments; 12 underwent caudal block, 9 IV fentanyl anesthesia, and 7 were given penile block. The mean first postvoid bladder residual volumes were highest in the caudal and lowest in the penile block children (27.5 vs. 17.3 mL, P = 0.003). The time elapsing between the end of surgery and first voiding was the longest in the fentanyl group compared with caudal and penile blocks (232, 178, 150 minutes, respectively, P = 0.02).

CONCLUSIONS

None of the anesthetic techniques provoked postoperative urinary retention after minor penile surgery in children. The penile block appears superior to caudal block or to IV fentanyl-based anesthesia with regard to postoperative recovery of normal micturition.

Postoperative urinary retention or difficulties to empty the bladder in young patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis

BACKGROUND

Postoperative urinary retention has been reported to affect up to 27% of adults undergoing degenerative lumbar spine surgery and approximately one-third of children undergoing lower-extremity orthopedic surgery. No data exist on the incidence and risk factors of postoperative urinary tract retention/difficulties to empty the bladder in young patients undergoing instrumented posterior spinal fusion. We aimed to characterize incidence, risk factors and treatment of postoperative urinary retention (POUR) and difficulties to empty the bladder in young patients undergoing posterior spinal fusion (PSF) for idiopathic scoliosis.

METHODS

One hundred and eleven consecutive patients (mean age 16years [range, 11-21years], 81 females and 30 males) undergoing PSF for adolescent idiopathic scoliosis were screened after removal of urinary catheter postoperatively for inability to void and residual volume of urinary bladder. The latter was measured using ultrasound on two separate occasions. POUR and the need for intermittent catheterization were defined as an inability to void after catheter removal and documented full bladder with ultrasound (a residual of 300mL or more) or a significant residual volume after voiding (>2mL/kg or >100mL).

RESULTS

Fifty-one (46%) of the patients were either unable to void or had a clinically significant amount of residual volume after voiding. These fifty-one patients required intermittent catheterization for a mean of two days. Thirty patients (27%) had POUR, a residual volume of 300mL or more. Two (1.8%) patients experienced urinary tract infection postoperatively. Patients with urinary retention had a significantly higher mean intraoperative blood loss (mean 626mL vs. 464mL; p=0.020) and longer operation time (mean 3.3h vs. 2.8h; p=0.009) as compared with those not having urinary retention. In multivariate analyses the main risk factor for urinary retention was male gender (odds ratio 3.2 [95% confidence interval 1.1-9.2], p=0.028).

CONCLUSIONS

Postoperative voiding difficulties affect almost half of the patients with age under 21years undergoing PSF for idiopathic scoliosis. The main risk factors were increased intraoperative blood loss, longer length of surgery and male gender. POUR should be actively screened and treated in this patient population.

LEVEL OF EVIDENCE

Prospective Cohort Study II.

Unusual case of acute urinary retention in a young female

We report an unusual case of a 17-year-old young female presenting to the emergency department with varicella infection, acute urinary retention (AUR) and no other neurological deficits. An MRI of the spine confirmed the diagnosis of acute transverse myelitis. Positive serum IgG antibodies against varicella zoster virus (VZV) suggested a parainfectious aetiology. The patient eventually developed weakness and a sensory level from the third thoracic dermatome on day 2 of hospitalisation. Awareness that AUR can precede other neurological deficits in VZV transverse myelitis will prevent misdiagnosis and allow for the prompt treatment of this debilitating illness.

Benign prostatic hyperplasia: Case report of a 17-year-old

INTRODUCTION

Benign prostatic hyperplasia (BPH) is generally common in men older than 50 years of age but is extremely rare in childhood. In the literature to date, fewer than five cases have been reported under 18 years of age. Owing to the limited number of cases, the etiology and management of BPH in the first two decades is not clear.

OBJECTIVE

We herein report a 17-year-old boy who presented with acute urinary retention due to BPH and was treated with endoscopic transurethral resection of the prostate (TUR-P).

CASE REPORT

A 17-year-old male patient with a history of intermittent hematuria was admitted elsewhere with acute urinary retention. An increase in prostate size was detected on digital rectal examination. Pelvic ultrasound revealed a large mass arising from the prostate and filling the bladder lumen. Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) was performed to exclude malignancy. After the documentation of benign prostate tissue in the histopathological analysis, the patient was referred to our clinic for further evaluation and management. Magnetic resonance (MR) imaging revealed a 48 × 55 × 68 mm mass arising from the middle lobe of prostate and filling the bladder lumen (Figure) with an initial diagnosis of a non-ductal malignant tumor because of his age. Enlarged lymph nodes or any sign of metastasis were not detected. Re-examination of the previous biopsy specimens confirmed the absence of malignancy; therefore he underwent endoscopic treatment with TUR-P. Histopathological examination reported BPH. The postoperative 1-year follow-up was uneventful.

DISCUSSION

The patient was extensively evaluated with a suspicion of malignancy, especially rhabdomyosarcoma, which is more expected for this age group. Reviewing juvenile cases with BPH in the literature, two authors explained the possible etiologic factors of their cases as gonadotropin supplement therapy for undescended testes and the mother's utilization of a human chorionic gonadotropin-containing agent during pregnancy to prevent spontaneous abortion. Our case had no history of drug intake, endocrinologic abnormality, or any other possible relevant factor. Owing to the limited number of cases, there is not enough data to understand the etiology and also no consensus on the treatment of BPH in the adolescents. Therefore, experiences gained from adult cases guide the pediatric treatment modalities.

CONCLUSION

Despite the fact that BPH is very rare in childhood, one should keep it in mind in the differential diagnosis of acute urinary retention and malignant prostate diseases. The endoscopic method is the treatment of choice in BPH.

[Acute urinary retention in a pre-school girl with constipation]

OBJECTIVE

To report a case of a preschool girl who developed acute urinary retention associated with constipation.

CASE DESCRIPTION

A girl aged six years old presented a 24 hour history of inability to urinate. She was went twice to the emergency room during this period. In the first admission, 12 hours after the onset of the symptoms, she presented abdominal pain and acute urinary retention. After the drainage by urinary catheterization of 300 mL of clear urine, she presented relief of the symptoms and, as urinalysis had no change, the patient was discharged home. Twelve hours after the first visit, she returned to the emergency room complaining about the same symptoms. At physical examination, there was only a palpable and distended bladder up to the umbilicus with no other abnormalities. Again, a urinary catheterization was performed, which drained 450 mL of clear urine, with immediate relief of the symptoms. Urinalysis and urine culture had no abnormalities. During the anamnesis, the diagnosis of constipation was considered and a plain abdominal radiography was performed, which identified large amount of feces throughout the colon (fecal retention). An enema with a 12% glycerin solution was prescribed for three days. During follow-up, the child used laxatives and dietary modifications, this contributed to the resolution of the constipation. There were no other episodes of urinary retention after 6 months of follow-up.

COMMENTS

Acute urinary retention in children is a rare phenomenon and constipation should be considered as a cause.

Extraordinary cause of complete colonic obstruction in children: urinary retention

Complete colonic obstruction in children may occur secondary to congenital, and acquired factors related to the gastrointestinal system. Herein, we report an extraordinary presentation of complete colonic obstruction due to extensive urinary retention in a 3-year-old boy. The possible underlying mechanism was detected as urinary infection in a child with horseshoe kidney. The treatment of the bladder symptoms and urinary infection relieved the obstruction of the colon. To our knowledge, especially in children, colonic obstruction due to urinary retention has not been reported in the literature.

Renal relevant radiology: use of ultrasonography in patients with AKI

As judged by the American College of Radiology Appropriateness Criteria, renal Doppler ultrasonography is the most appropriate imaging test in the evaluation of AKI and has the highest level of recommendation. Unfortunately, nephrologists are rarely specifically trained in ultrasonography technique and interpretation, and important clinical information obtained from renal ultrasonography may not be appreciated. In this review, the strengths and limitations of grayscale ultrasonography in the evaluation of patients with AKI will be discussed with attention to its use for (1) assessment of intrinsic causes of AKI, (2) distinguishing acute from chronic kidney diseases, and (3) detection of obstruction. The use of Doppler imaging and the resistive index in patients with AKI will be reviewed with attention to its use for (1) predicting the development of AKI, (2) predicting the prognosis of AKI, and (3) distinguishing prerenal azotemia from intrinsic AKI. Finally, pediatric considerations in the use of ultrasonography in AKI will be reviewed.

Urologic outcomes of pediatric pelvic neuroblastoma presenting in acute urinary retention

PURPOSE

To evaluate long-term urologic outcomes of patients with pelvic neuroblastoma (NB) presenting with urinary retention.

METHODS

Five cases of pelvic NB presenting with urinary retention were identified between 1971 and 2011. Clinical presentation, treatment, survival and long-term voiding outcomes were analyzed.

RESULTS

All five patients presented with acute urinary retention and pelvic outlet dysfunction including bladder perforation (20%), constipation (40%), or fecal incontinence (20%). The presenting age ranged from 7 days to 4 years with female to male ratio of 3:2. Two patients presented with bilateral hydronephrosis and three patients were stage 4 at presentation. All required debulking surgery, four patients required combined anterior and posterior approaches for tumor resection, with two patients requiring concurrent laminectomy. Adjuvant or neoadjuvant chemoradiation was used in four of five cases. Follow-up ranged from 2 to 41 years. Although the long-term oncological outcome is favorable, urologic outcomes of these patients ranged from normal bladder function to the need significant reconstructive procedures.

CONCLUSION

Urologic outcomes are related to pelvic nerve and organ preservation during resection more than the severity of urinary symptoms at presentation.

Acute Urinary Retention in a 47-month-old Girl Caused by the Giant Fecaloma

We present a case of a 47-month-old female suffering from acute urinary bladder neck obstruction and bilateral hydronephrosis secondary to a fecaloma. Fecaloma is defined as an accumulation of inspissated feces in the colon or rectum giving the appearance of an abdominal mass. A fecaloma can be developed by diverse causes and the causes of the fecaloma in this case were septum reformation after the Duhamel procedure and long-term constipation. Chronic constipation is very common at outpatient clinic. However, acute urinary retention and voiding difficulty caused by fecaloma in the giant Duhamel pouch has never been reported in Korea. We would like to present our case with acute urinary retention due to a fecaloma and suggest that fecaloma might be considered as one of the causes for acute urinary retention, especially in cases with previous Duhamel operation for repair of Hischsprung disease.

[Systemic adverse effects of topical ocular instillation of atropine in two children]

A medication-related cause must be sought when unusual symptoms occur. Topical treatments, including eye drops, whose side effects are more common in exposed children, need to be verified. We report here the cases of two children who developed systemic symptoms after the administration of atropine-based mydriatic eye drops. A 6-month-old boy was admitted to the emergency department with acute urine retention lasting 36h. Investigations identified only eye drop treatment 3h before the onset of symptoms, with 2 drops of homatropine 1 %, as a cause. No other urinary retention was observed during the 1-year follow-up. A 2-year-old boy was admitted to the emergency department for drowsiness, thirst, and dry mouth 30min after the administration of three eye drops of atropine 1 % instead of atropine 0.3 % (error made by the pharmacy). Symptoms disappeared after 6h. Both observations highlight the possible side effects related to mydriatic eye drops. Indeed, because of small penetration of such medications in the eye, a high concentration of the active part of the medication is contained in each drop. In young children, at least 20 to 40 % of the volume of a drop drains into the nasolacrimal duct and thereby into the systemic circulation, without passage through the liver. A close national pharmacologic vigilance follow-up has been set up for atropine-based mydriatic eye drops in young children, who are the most exposed to systemic and potentially severe complications of these medications. We emphasize the appropriate procedure for the use of eye drops in young children to limit systemic passage, with only a 0.3 % maximum atropine concentration in infants, compression of the internal angle of the eye for at least 1min, and at least a 15-mins interval between two eye drop administrations.

Eosinophilic meningitis caused by Angiostrongylus cantonensis in an adolescent with mental retardation and pica disorder

Eosinophilic meningitis or encephalitis is a rare disorder and is most commonly caused by Angiostrongylus cantonensis. Humans are accidentally infected when they ingest raw snails or vegetables contaminated with the parasite larvae. Because of the improvement in sanitary food handling practices, the occurrence of A. cantonensis eosinophilic meningitis has been decreasing in Taiwan in recent decades. The common symptoms and signs of eosinophilic meningitis are severe headache, neck stiffness, paresthesia, vomiting, nausea, and fever. Acute urinary retention is a rare presentation. We report a case of A. cantonensis eosinophilic meningitis in an intellectually disabled patient who presented with acute urinary retention without any other meningeal signs. The patient received supportive treatment with corticosteroid therapy and was discharged and received urinary rehabilitation at home.

Urinary retention in an adolescent with a history of urethral transection

BACKGROUND

Urinary retention is rare in adolescence. Here I describe such a case in a patient who had transected her urethra in a motor vehicle accident at 3 years of age. The presumptive diagnosis of urethral stricture was proven incorrect.

OBJECTIVES

Both to present a complicated and unique case whose history pointed strongly to one diagnosis initially but turned out very differently than expected; and to give an example of the use of bedside ultrasonography in the Emergency Department as a diagnostic tool in an unusual circumstance.

CASE REPORT

A 13-year-old girl was evaluated for 3 days of urinary retention. Her history of pelvic fracture and urethral transection in childhood suggested a urethral stricture. Her work-up revealed, however, a vaginal stricture and resultant hematocolpos compressing the urethra. Upon surgical excision, the stricture was confirmed to be scar tissue, rather than a coincidental congenital septum.

CONCLUSION

Hematocolpos is an uncommon but well-described cause of urinary retention in premenarchal females. This is a difficult diagnosis in any circumstance, and this patient's complex history complicated the process. It was the bizarre bedside ultrasound that prompted further work-up than simple urethral catheterization and urologic follow-up, which her urologist had suggested over the phone. This patient's case is unique in the literature.

Psychogenic urinary retention in children: a case report

Psychogenic urinary retention occurs relatively infrequently in children and is less common than in adults. The influence of psychogenic factors on voiding generally results in an irritative syndrome, but rarely in urinary retention. A definitive diagnosis is established by excluding other pathological conditions. Evaluation includes urine culture, renal echography, spine magnetic resonance imaging, voiding cysto-urethrography, intravenous pyelography, and uroflowmetry. Here, we report on a 6-year-old girl with a 1-month history of voiding difficulty. Urology studies, including urine culture, revealed Escherichia coli, which was not present in preadmission urine cultures. Renal ultrasound and radiological images showed no gross abnormalities or vesicoureteral reflux, but uroflowmetry showed a low flow rate with residual urine. The results of imaging studies and pediatric psychiatric consultation led to a diagnosis of psychogenic urinary retention combined with urinary tract infection. Urinary rehabilitation included intermittent catheterization, bladder training, and supportive psychotherapy, after which the patient recovered and was discharged.

Evaluation of a non-invasive bladder volume measurement in children

OBJECTIVE

Postoperative urinary retention (PUR) is associated with overdistension of the bladder. The prevention of PUR by routine catheterization may increase the risk of urinary tract infection. Postoperative monitoring of the bladder volume by ultrasound to prevent PUR is reliable in adults, but has not been evaluated in children.

MATERIAL AND METHODS

The BladderScan BVI 6200, an ultrasound device specifically designed for children, was assessed. Forty patients who required urinary catheter placement during surgery or during intensive care unit stay were entered into this blinded calibration study. An assessment of bladder urine volume by ultrasound was performed before and after catheterization in surgical patients. In these patients and intensive care patients 0, 2.5 or 5 ml/kg sterile normal NaCl was injected through the bladder catheter and the catheter was clamped. Volumes estimated with ultrasound were compared with measured catheter drainage or/and injected volume after the scan.

RESULTS

The mean relative difference (bias) between the ultrasound estimate and the injected volume was -20% (95% confidence interval 140 to -180%). Precision, estimated using the Wilcoxon signed ranks test, showed a significant difference (Z = -3.25, p = 0.001) between the ultrasound-estimated volumes and the injected volumes.

CONCLUSIONS

This study could not confirm good agreement between the ultrasound-estimated volumes and the injected volumes at volumes below 5 ml/kg. Bladder volumes were underestimated with a very broad 95% confidence interval. The ultrasound device should not replace current clinical assessment.

Imperforate hymen and urinary retention in a newborn girl

Urinary retention is relatively rare in infants,especially in girls. Imperforate hymen is the most frequent congenital malformation of the female genital tract and is usually asymptomatic until puberty. Mucocolpos with an abdominal mass in neonatal age is extremely rare. We report a case of a 20-day-old newborn girl with acute urinary retention due to isolated imperforate hymen and mucocolpos.

Acute urinary retention in a 7-year-old girl: an unusual complication of cytomegalovirus cystitis

Acute urinary retention in children is rare. There are a variety of causes about the disease. We report a case of a 7-year-old girl with acute urinary retention and hematuria. Pelvic sonogram revealed an isoechoic mass in the urinary bladder that appeared as a lobulated filling defect over the bladder neck on intravenous urography and computed tomography studies. The surgical specimen from cystoscopic examination showed reactive changes on pathologic analysis. Cytomegalovirus was isolated from urine culture. The girl recovered after supportive treatment.

Investigating time to void after lower-extremity orthopedic surgery in a pediatric population

PURPOSE

This study aims to determine the time frame of postoperative bladder volume assessment in order to identify children at risk for urinary retention in a pediatric orthopedic population.

DESIGN AND METHODS

This is a descriptive and nonexperimental study. Variables included age, sex, length of anesthesia, type of analgesia, analgesia delivery, bladder volume, and intravenous fluid rate.

RESULTS

Twenty-nine percent of the children (n = 38) required straight catheterization. The average length of time to bladder emptying was 5 hr. There were significant correlations (p < .05) between several variables.

PRACTICE IMPLICATIONS

The standard practice of waiting 8 hr before assessment of voiding was not supported in this study.

Management principles of organic causes of childhood constipation

Constipation is extremely common in the pediatric population; however, it is a symptom and not a disease. Organic causes of constipation include Hirschprung's disease, anorectal malformation, and spina bifida. This article also discusses constipation and urinary tract pathology and dysfunction. The function of the gastrointestinal and urinary tracts are intertwined, and this concept will assist the practitioner in managing patients accordingly. Children and adolescents who experience bowel dysfunction require patience and sensitive support from their health care providers so that they can live productive and emotionally healthy lives.

Acute urinary retention as the presentation of imperforate hymen

Acute urinary retention is unusual in children and is usually a candidate for visiting the emergency department upon initial discovery. We report a 12-year-old girl who complained of acute urinary retention. Ultrasonography demonstrated a large echogenic mass over the vagina and mild dilation of the uterus. Imperforate hymen associated with hematocolpos and hematometrium was diagnosed. Cruciate hymenotomy was performed. The symptoms resolved after treatment. Adolescent girls who complain of urinary symptoms with no previous menstruation should have their external genitalia examined in order to rule out the possibility of imperforate hymen as the cause of acute urinary retention.

A 16-year-old boy with acute urinary retention

Urinary retention can be described as the inability to void volitionally despite an adequate volume of urine in the bladder. It is a common complaint in adults, especially among elderly males with benign prostatic hyperplasia. Children, in contrast, are more likely to have voluntary retention of urine due to urethral irritation or dysuria. Gently massaging the suprapubic region while the child is in a warm bath often relieves the retention in these cases. Other patients described as lazy voiders can present with acute urinary retention. These patients are typically young girls who are embarrassed to void at school. Retraining or timed voiding is often successful managing lazy voiders. However, these benign disorders should only be diagnosed after anatomical or organic causes for their symptoms have been considered and ruled out.

Acute urinary retention in a 9-year-old child: an atypical presentation of acute appendicitis

Acute urinary retention is unusual in childhood and when present is likely to have an identifiable cause. Although the evaluation is often performed by the urologic specialist after relief of the obstruction, it is imperative that some causes be identified in the Emergency Department. This is a case of a 9-year-old boy in acute urinary retention caused by a ruptured appendix with a periappendiceal abscess.

Pediatric urologic emergencies and urgencies

The more common urologic problems seen in infancy and childhood that require urgent or emergent pediatric urologic referral are discussed, including a brief description of the usual presenting signs or symptoms, differential diagnoses, proper diagnostic work-up recommended before or at the time of referral, and the usual therapeutic course of management after evaluation by the urologist. These conditions include the acutely swollen scrotum, scrotal masses, penile swelling and erythema, exstrophy, hematuria, urinary retention, abdominal masses, and various genital abnormalities including interlabial masses, hypospadias with any degree of cryptorchidism, and ambiguous genitalia. This article is designed to provide the primary care practitioner with a focused review and a useful resource for managing children who have genitourinary abnormalities in the hospital or clinic setting.

Acute urinary retention due to benign inflammatory nervous diseases

Both neurologists and urologists might encounter patients with acute urinary retention due to benign inflammatory nervous diseases. Based on the mechanism of urinary retention, these disorders can be divided into two subgroups: disorders of the peripheral nervous system (e.g., sacral herpes) or the central nervous system (e.g., meningitis-retention syndrome [MRS]). Laboratory abnormalities include increased herpes virus titers in sacral herpes, and increased myelin basic protein in the cerebrospinal fluid (CSF) in some cases with MRS. Urodynamic abnormality in both conditions is detrusor areflexia; the putative mechanism of it is direct involvement of the pelvic nerves in sacral herpes; and acute spinal shock in MRS. There are few cases with CSF abnormality alone. Although these cases have a benign course, management of the acute urinary retention is necessary to avoid bladder injury due to overdistension. Clinical features of sacral herpes or MRS differ markedly from those of the original "Elsberg syndrome" cases.

Pharmacological agents used for the treatment of stress urinary incontinence in women

Stress urinary incontinence (SUI) is the involuntary loss of urine associated with physical activities such as running, jumping, or lifting, or with sneezing and coughing. For many patients it can be a very bothersome symptom, causing social isolation, loss of self-esteem, and increased expenses. Although there is currently no single medication approved worldwide for the treatment of SUI, a variety of off-label agents are often prescribed. This paper reviews the current pharmacological treatment options for SUI, describing the mechanism of action, efficacy, and possible adverse effects of each. A new centrally-acting compound with dual activity as a balanced serotonin and norepinephrine reuptake inhibitor, duloxetine, may offer a promising new approach for treatment.

Use of ultrasound bladder monitoring in children after caudal anaesthesia

Urinary retention occurring after caudal anaesthesia in children has a low incidence. Most children will void within 12 h of surgery, although the incidence of retention is higher after hypospadias repair. However, overdistention causing bladder atony that is temporary, or may become permanent, is described in adults. Long-term effects of overdistention in children have not been described. Urine volume, used to describe overdistention, is traditionally measured after catheterization. We report two children suffering from urine retention after caudal anaesthesia (bupivacaine 0.25%) was used to supplement a general anaesthetic. Ultrasound bladder monitoring was used to assist with the clinical diagnosis of bladder distension in the postanaesthesia care unit (PACU) and subsequent management. In-out catheterization was required in a 1-year-old-girl with a bladder volume of 12 ml.kg-1 after external manual compression over the bladder was unable express urine. Spontaneous micturation occurred within the subsequent 8 h. A 10-year-old boy suffered distress in PACU with a bladder volume, measured by ultrasound, of 5 ml.kg-1. Catheterization relieved distress and spontaneous micturation returned 18 h after surgery. Measured urine volumes were similar to those estimated by ultrasound. Ultrasound bladder monitoring is a simple, noninvasive technique that can be used to assist with the diagnosis and management of urinary retention in children. It may replace catheterization as the prefered technique to measure urine volume. The correlation between measured bladder volumes and urine volume appears reasonable. A volume of approximately 10 mg.kg-1 may be considered as causing overdistension.

Office laboratory procedures, office economics, parenting and parent education, and urinary tract infection

We once again review four areas of interest to office-based pediatricians: office laboratory procedures, office economics, parenting and patient education, and urinary tract infections. Sean Elliott reviews the current status of the Clinical Laboratories Improvement Amendments (CLIA) and their continuing impact on physician office laboratories. Eve Shapiro reviews office economics, this year focusing on managed care, the physician workforce, practice management, and health care financing for the uninsured. Anna Binkiewicz provides an update on parenting and parent education, with recent reports on nutrition and childhood immunizations. Richard Wahl again reviews recent research on urinary tract infection, discussing voiding physiology, dysfunctional voiding patterns, acute urinary retention, urine collection techniques, diagnosis in young infants, and antibiotic prophylaxis.