Some genitourinary cases are far from textbook: new data on epididymitis contradict the traditional practice of antibiotic treatment in all cases.

SAN DIEGO -- Many pediatric textbooks recommend antibiotics for children with epididymitis, but recent data do not support that practice in all patients.

"Children with epididymitis rarely have positive cultures, so they probably do not need antibiotics and can be managed expectantly in selected cases," Dr. Marianne Gausche-Hill said at a pediatric emergency medicine meeting sponsored by the American College of Emergency Physicians.

In a prospective study of 48 children with epididymitis who were followed for a mean of 3 months, 36 cases with a negative urinalysis were treated without antibiotics, and 12 cases were treated with antibiotics (Br. J. Urol. 1997;79:797-800). All cases resolved without complication.

However, infants younger than 3 months represent a special age group that should receive antibiotic therapy. One single-center study of seven infants younger than 3 months with testicular torsion and epididymo-orchitis found that five had fever and scrotal tenderness, two had pyuria, and four had bacteruria (J. Pediatr. Surg. 2007;42:1574-7). All had positive urine or blood cultures.

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In general, most cases of epididymitis in children are secondary to a urinary tract infection, such as those caused by Mycoplasma species, Escherichia coli, and Staphylococcus aureus. The condition may also be associated with urinary tract pathogens such as paramyxovirus, adenovirus, Coxsackie virus, and echovirus. In adolescents, epididymitis can be caused by gonorrhea and chlamydia.

Dr. Gausche-Hill's algorithm for children with epididymitis includes obtaining urinalysis, Gram stain, culture, and color Doppler ultrasound to confirm the condition.

For infants younger than 3 months, she also obtains a complete blood count, a blood culture, and a C-reactive protein level.

If testing confirms epididymitis in infants younger than 3 months, she recommends hospital admission and IV antibiotics. "I would also consider hospital admission for older patients who have signs of toxicity, such as dehydration, inability to tolerate oral antibiotics, failure of outpatient management, or signs of sepsis," said Dr. Gausche-Hill, director of EMS and pediatric emergency medicine fellowships at Harbor-UCLA Medical Center, Torrance, Calif.

For children older than 3 months, she initiates antibiotic therapy only if the urinalysis or Gram stain is positive. Her inpatient antibiotic of choice is ampicillin plus gentamicin, or ampicillin plus cefotaxime. Her outpatient antibiotic of choice is cephalexin; a macrolide can be added if the child remains symptomatic.

In adolescents, she sends a urine sample for gonorrhea and chlamydia testing and/or performs a urethral swab. If test results confirm infection, she treats with ceftriaxone 250 mg IM plus doxycycline 100 mg by mouth twice daily for 10 days.

Dr. Gausche-Hill discussed other common genitourinary emergencies that affect young males:

* Testicular torsion. She described the case of a 3-year-old boy who presented to the emergency department with 2 hours of right scrotal swelling. The mother stated that he started to cry after he ate his lunch, and vomited. Physical exam revealed a horizontal lie of the testis, erythema and swelling, and negative cremasteric reflex--all classic signs of testicular torsion.

The first step in managing a child with testicular torsion is to call a urologist for surgical exploration, because the sooner the child can be operated on, the better the chances of being able to salvage the testis. The salvage rates are 80% for those who have surgery within 5 hours of symptoms appearing, compared with 20% within 12 hours and 0% within 24 hours. "From a medicolegal standpoint, health care professionals not only fail to diagnose this on the first visit, but they fail to act in a timely manner," Dr. Gausche-Hill said. "Time is testis."

In the case she described, the boy was taken to the operating room, where he underwent orchiopexy for testicular torsion without any diagnostic testing, "which is what I think should be the standard of care."

She added that undescended testes are 10 times more likely to experience torsion than normally descended testes. "So, if you have a patient with right lower quadrant pain, make sure you examine the genitourinary area, regardless of the age," she said. "Teenagers do not want you to look in that area, but I just tell them that they're not leaving without me looking."

Diagnostic testing with color Doppler ultrasound is not perfect. In a study of 77 patients aged 1 day to 17 years, 10 had acute symptoms and signs of torsion in the operating room, but only 9 had actual torsion (J. Urol. 1993;150:667-9). Of the 67 who underwent color Doppler ultrasound, 32 had normal flow in and around the testis, and 23 had increased flow (2 of these had intermittent torsion). In addition, 12 had no flow demonstrated (5 had acute torsion and 7 had necrotic testis).

"Does a negative color Doppler ultrasound mean that the child does not have testicular torsion? No," said Dr. Gausche-Hill, who is also a professor of medicine at the University of California, Los Angeles. "Multiple studies show poor sensitivity of the test (in the range of 63%-90%), but great specificity (in the range of 97%-100%)."

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One study of 172 patients found that the following three factors were highly suggestive of testicular torsion: testicular pain lasting less than 6 hours, an absent or decreased cremasteric reflex, and nausea / vomiting (Pediatr. Radiol. 2005;35:302-10).

If none of those factors was present, none of the patients had testicular torsion. If all three were present, 87% of patients were found to have testicular torsion.

* Phimosis. Dr. Gausche-Hill described the case of a 6-year-old by who presented to the emergency department because each time he urinated, his penis swelled and then reduced in size as the urine flowed out. There was no pain with urination and no fever.

Those symptoms mark the classic signs of phimosis, which accounts for 3% of complications involving the foreskin in uncircumcised males. At birth, about 95% of uncircumcised boys have adhesions that prevent the foreskin from being retracted over the glans. This drops to less than 10% by the time the child enters school, and to less than 1% by the time the child reaches age 17 years.

"I find that parents get overly anxious about phimosis," she said. "The bottom line is, if you're not circumcised, the foreskin is not retractable until they're about 2 years of age. Usually by school age, about 95% of the foreskin is retractable."

Multiple studies have demonstrated that surgery can be avoided in up to 88% of cases by applying steroid cream to the end of the phimosis area twice a day for 4-8 weeks. Agents that have been studied include mometasone furoate 0.1% (Elocon), betamethasone dipropionate 0.05% (Maxivate), and triamcinolone 0.1% (Aristocort).

Refer to urology if phimosis persists.

* Paraphimosis. This uncommon condition occurs when the prepuce is retracted over the glans penis and then cannot be moved into normal position over the glans. Physical exam reveals a swollen glans and distal prepuce. "Verify that the patient is uncircumcised, because hair tourniquet syndrome may mimic paraphimosis," Dr. Gausche-Hill advised.

Management involves reduction of the prepuce back over the glans. Manual reduction is her choice technique. Other options for reduction include placing an ice pack to the groin or Ace wrap to the penis to reduce swelling; soaking the penis in a glucose-saturated gauze; puncturing the swollen prepuce with a fine needle to allow edema fluid to escape; and the DeVries technique, which calls for injection of a solution of hyaluronidase (two to three sites). For each of these methods, oral analgesics, application of a topical anesthetic such as EMLA, procedural sedation, and a penile block for pain control may be needed.

Dr. Gausche-Hill had no relevant disclosures to make.

BY DOUG BRUNK

San Diego Bureau DATA WATCH Percentage of U.S. Children Under Age 6 Years With Elevated Blood Lead Levels Decreasing Drastically 1997 7.6% 1998 6.5% 1999 5.0% 2000 4.0% 2001 3.0% 2002 2.6% 2003 2.0% 2004 1.8% 2005 1.6% 2006 1.2% Source: The Foundation for Child Development Note: Table made from line graph.