Chapter 41: Genitourinary Disorders

Garzon Maaks: Burns’ Pediatric Primary Care, 7th Edition

MULTIPLE CHOICE

1. A 30-month-old girl who has been toilet trained for 6 months has daytime enuresis and
dysuria and a low-grade fever. A dipstick urinalysis is negative for leukocyte esterase and
nitrites. What is the next step?
a. Begin empiric treatment with trimethoprim-sulfamethoxazole.
b. Discuss behavioral interventions for toilet training.
c. Reassure the child’s parents that the child does not have a urinary tract infection.
d. Send the urine to the lab for culture.
ANS: D
Girls over age 24 months have a higher risk than boys for UTI. This child is symptomatic, so
her urine should be cultured even though the leukocyte esterase and nitrites are negative; urine
in the bladder less than 4 hours may be tested as negative for leukocyte esterase. Empiric
treatment may be initiated if the child had signs of sepsis. Behavioral interventions are not
indicated – the child has dysuria and fever along with enuresis. Until the culture is found to be
negative, it is not certain that the child does not have an UTI, and thus reassurance is not the
correct action.

2. The clean catch urine specimen of a child with dysuria, frequency, and fever has a colony
count between 50,000 and 100,000 of E. coli. What is the treatment for this child?
a. Obtain a complete blood count and C-reactive protein.
b. Perform sensitivity testing before treating with antibiotics.
c. Repeat the culture if symptoms persist or worsen.
d. Treat with antibiotics for urinary tract infection.
ANS: D
If children are symptomatic and have more than 10,000 colonies of a single pathogen, they are
considered to have a UTI and are treated. If pyelonephritis symptoms such as flank pain and
sepsis are present, CBC and CRP are useful tests. Sensitivity testing is done for patients who
appear toxic, have pyelonephritis, or are non-responsive to antibiotics.

3. A dipstick urinalysis is positive for leukocyte esterase and nitrites in a school-age child with
dysuria and foul-smelling urine but no fever who has not had previous urinary tract infections.
A culture is pending. What will the pediatric nurse practitioner do to treat this child?
a. Order ciprofloxacin ER once daily for 3 days if the culture is positive.
b. Prescribe trimethoprim-sulfamethoxazole (TMP) twice daily for 3 to 5 days.
c. Reassure the child’s parents that this is likely an asymptomatic bacteriuria.
d. Wait for urine culture results to determine the correct course of treatment.
ANS: B
Short-term antibiotics of 3 to 5 days may be as effective for treating UTI in non-febrile
bladder infections and TMP is generally a first-line drug in children without history of UTI.
Ciprofloxacin is used in adolescents older than 18 years and this child is symptomatic with
positive leukocyte esterase and nitrites and will need treatment. Asymptomatic bacteriuria
occurs when bacteria are in the urine of a child who is asymptomatic (without symptoms).
4. A preschool-age child with no previous history has mild flank pain and fever but no
abdominal pain or vomiting. A urinalysis is positive for leukocyte esterase and nitrites. A
culture is pending. Which is the correct course of treatment for this child?
a. Hospitalize for intravenous antibiotics.
b. Order amoxicillin clavulanate.
c. Prescribe trimethoprim-sulfamethoxazole.
d. Refer for a voiding cystourethrogram.
ANS: B
These symptoms suggest this young child may have pyelonephritis. Amoxicillin clavulanate
may be given to young children with uncomplicated pyelonephritis who are well hydrated
with no abdominal pain or vomiting. Hospitalization is not necessary for uncomplicated
pyelonephritis in this age child. TMP is not a first-line drug for pyelonephritis. Voiding
cystourethrogram is not indicated for a first febrile UTI.

5. A 3-year-old child has just completed a 7-day course of amoxicillin for a second febrile
urinary tract infection and currently has a negative urine culture. What is the next course of
action?
a. Obtain a renal and bladder ultrasound.
b. Prescribe prophylactic antibiotics to prevent recurrence.
c. Refer the child for a voiding cystourethrogram.
d. Screen urine regularly for leukocyte esterase and nitrites.
ANS: A
Children with recurrent UTI should have a renal and bladder US to assess for hydronephrosis,
scarring, or other atypical findings. If the US is concerning, VCUG and/or DMSA screen may
be performed. Screening regularly is not indicated.

6. The parent of a toddler diagnosed with grade V vesicoureteral reflux asks the primary care
pediatric nurse practitioner how the disease will be treated. What will the nurse practitioner
tell this parent?
a. That long-term antibiotic prophylaxis will prevent scarring
b. That surgery to correct the condition is possible
c. that the child will most likely require kidney transplant
d. that the condition will probably resolve spontaneously
ANS: B
Children with grade V VUR generally do not experience spontaneous resolution and will
likely have to have surgery to correct the condition. Antibiotic prophylaxis will not necessarily
prevent scarring. Unless scarring occurs and is severe, kidney transplantation is not likely.

7. A healthy 14-year-old female has a dipstick urinalysis that is positive for 5-6 RBCs per hpf
but otherwise normal. What is the first question the primary care pediatric nurse practitioner
will ask this patient?
a. “Are you sexually active?”
b. “Are you taking any medications?”
c. “Have you had a recent fever?”
d. “When was your last menstrual period (LMP)?”
ANS: D
 Menstrual blood may appear in urine and is a common cause of urine with RBCs present, so
this would be an appropriate first question of an adolescent. Asking about sexual activity or
recent fevers may be part of the diagnostic reasoning if common causes are not present.
Medications may discolor the urine but do not cause RBCs to be present.

8. A child has gross hematuria, abdominal pain, and arthralgia as well as a rash. What diagnosis
is most likely?
a. Henoch-Schönlein purpura
b. Rhabdomyosarcoma
c. Sickle cell disease
d. Systemic lupus erythematosus
ANS: A
HSP may presents with gross hematuria in the presence of abdominal pain with or without
bloody stools, arthralgias, and a purpuric rash. Rhabdomyosarcoma is characterized by gross
hematuria and voiding dysfunction. Sickle cell disease can cause gross hematuria but not
always.

9. An adolescent has 2+ proteinuria in a random dipstick urinalysis. A subsequent first-morning

voided specimen is negative. What will the primary care pediatric nurse practitioner do to
manage this condition?
a. Monitor for proteinuria at each annual well child examination.
b. Order a 24-hour timed urine collection for creatinine and protein excretion.
c. Reassure the parents that this is a benign condition with no follow-up needed.
d. Refer the child to a pediatric nephrologist for further evaluation.
ANS: A
Orthostatic proteinuria, demonstrated by proteinuria of greater than 1+ with activity and low-
protein to normal urine on a first-morning void, is common in adolescents. If the first-morning
void is negative, the adolescent should be monitored annually. A 24-hour urine collection is
not indicated unless the first-morning void is elevated. Although the orthostatic proteinuria is
mostly benign, annual monitoring is recommended and patient education should stress the
importance of follow-up to evaluate the cause of proteinuria. Children with mild
asymptomatic proteinuria who have a normal first-morning specimen do not require extensive
testing for kidney disease but should be monitored annually. Unless proteinuria is severe or
persistent, referral to a nephrologist is not indicated.

10. A child is diagnosed with nephrotic syndrome, and the pediatric nurse practitioner provides
primary care in consultation with a pediatric nephrologist. The child was treated with steroids
and responded well to this treatment. What will the nurse practitioner tell the child’s parents
about this disease?
a. “Future episodes are likely to have worse outcomes.”
b. “Steroids will be used when relapses occur.”
c. “This represents a cure from this disease.”
d. “Your child will need to take steroids indefinitely.”
ANS: B
 In situations in which a child responds well to steroids, this shows promise of a good
prognosis, indicating that the child may be treated successfully with steroids during future
anticipated relapses. The fact that a child is a “steroid responder” indicates that future
episodes of treatment will be successful and have positive outcomes. This disease is chronic
and not curable. Steroid use with children who respond positively is intermittent during
episodes of relapse. Steroids are not given continuously and are not seen as prophylactic.

11. A child who has nephrotic syndrome is on a steroids and a salt-restricted diet for a relapse of
symptoms. A dipstick urinalysis shows 1+ protein, down from 3+ at the beginning of the
episode. In consultation with the child’s nephrologist, what is the correct course of treatment
considering this finding?
a. Begin a taper of the steroid medication while continuing salt restrictions.
b. Continue with steroids and salt restrictions until the urine is negative for protein.
c. Discontinue the steroids and salt restrictions now that improvement has occurred.
d. Relax salt restrictions and continue administration of steroids until proteinuria is
gone.
ANS: B
Steroid medications and salt restrictions are continued until proteinuria resolves.

12. A child diagnosed with Group A beta-hemolytic streptococci (GABHS) 2 weeks prior is in the
clinic with periorbital edema, dyspnea, and elevated blood pressure. A urinalysis reveals tea-
colored urine with hematuria and mild proteinuria. What will the primary care pediatric nurse
practitioner do to manage this condition?
a. Prescribe a 10- to 14-day course of high-dose amoxicillin.
b. Prescribe high-dose steroids in consultation with a nephrologist.
c. Reassure the parents that this condition will resolve spontaneously.
d. Refer the child to a pediatric nephrologist for hospitalization.
ANS: D
This child has symptoms of post-streptococcal glomerulonephritis and signs indicating a need
for hospitalization: elevated BP, edema, and dyspnea. The PNP should refer the child to a
nephrologist for hospital admission and care. Amoxicillin is not indicated; this condition is an
immunologic response to GABHS and not an infection. Steroids are not effective in treating
this disease. Although the condition usually does self-resolve, the child needs hospitalization
for close monitoring and follow-up.

13. An adolescent has right-sided flank pain without fever. A dipstick urinalysis reveals gross
hematuria without signs of infection or bacteriuria, and the primary care pediatric nurse
practitioner diagnoses possible nephrolithiasis. What is the initial treatment for this condition?
a. Extracorporeal shockwave lithotripsy (ESWL)
b. Increasing fluid intake up to 2 L daily
c. Percutaneous removal of renal calculi
d. Referral to a pediatric nephrologist
ANS: B
The first line of therapy for all stone types is increasing fluids. ESWL may be indicated if
symptoms worsen and stones are not passed. Percutaneous removal of renal calculi and
referral to nephrology may be indicated with worsening symptoms.
14. During a well child examination of a 2-year-old child, the primary care pediatric nurse
practitioner palpates a unilateral, smooth, firm abdominal mass which does not cross the
midline. What is the next course of action that?
a. Order a CT scan of the chest, abdomen, and pelvis.
b. Perform urinalysis, CBC, and renal function tests.
c. Reevaluate the mass in 1 to 2 weeks.
d. Refer the child to an oncologist immediately.
ANS: D
The finding is consistent with Wilms tumor, and referral, diagnosis, and treatment are urgent.
Palpating a mass too vigorously could lead to the rupture of a large tumor into the peritoneal
cavity so care should be taking in conducting the physical examination. The other tests may be
ordered by the oncology team. Treatment and diagnosis must occur immediately.

15. A 6-month-old infant has a retractile testis that was noted at the 2-month well baby exam.
What will the primary care pediatric nurse practitioner do to manage this condition?
a. Reassure the parent that the testis will most likely descend into place on its own.
b. Refer the infant to a pediatric urologist or surgeon for possible orchiopexy.
c. Teach the parent to manipulate the testis into the scrotum during diaper changes.
d. Tell the parent that hormonal therapy may be needed to correct the condition.
ANS: B
A retractile testis that does not retain scrotal residence should be referred to a pediatric
urologist or surgeon by 6 months of age. By that age, the child should be seen by a specialist
to rule out orchiopexy, in which the testis does not descend on its own (parental reassurance
would not be appropriate). Teaching the parent to manipulate the testis is not indicated.
Hormonal therapy has not demonstrated efficacy in stimulating testicular descent.

16. A 9-month-old infant is brought to the clinic with scrotal swelling and fussiness. The primary
care pediatric nurse practitioner notes a tender mass in the affected scrotum that is difficult to
reduce. What is the correct action?
a. Obtain an abdominal radiograph.
b. Refer immediately to a pediatric surgeon.
c. Schedule an appointment with a pediatric urologist.
d. Teach the parents signs of incarceration.
ANS: B
A scrotal mass that is difficult to reduce or is painful is likely to be a hernia. Immediate
referral is indicated to rule out incarceration, which is a medical emergency with potentially
severe consequences if not promptly treated. The PNP may order radiographs to distinguish a
hernia from a hydrocele, but not when these symptoms occur. The referral must be immediate,
since surgery is required. A child with a non-tender, reducible hernia will require referral, but
parents can be taught signs of incarceration until an appointment can be scheduled and the
specialist seen.

17. The mother of a 12-month-old uncircumcised male infant reports that the child seems to have
pain associated with voiding. A physical examination reveals a tight, pinpoint opening of the
foreskin, which thickened and inflamed. What will the primary care pediatric nurse
practitioner do?
a. Attempt to retract the foreskin to visualize the penis.
b. Order corticosteroid cream 3 times daily for 4 weeks.
 c. Refer the child to a pediatric urologist.
d. Teach the mother to gently stretch the foreskin with cleaning.
ANS: C
The child has symptoms consistent with pathologic phimosis and should be referred for
possible circumcision. The foreskin should never be forcefully retracted. Non-pathologic
phimosis can usually be managed by normal cleansing and gentle stretching. Corticosteroid
cream is used for persistent, non-pathologic phimosis.

18. An adolescent male comes to the clinic reporting unilateral scrotal pain, nausea, and vomiting
that began that morning. The primary care pediatric nurse practitioner palpates a painful,
swollen testis and elicits increased pain with slight elevation of the testis (a negative Phren’s
sign). What will the nurse practitioner do?
a. Administer IM ceftriaxone and prescribe doxycycline twice daily for 10 days.
b. Encourage bed rest, scrotal support, and ice packs to the scrotum as tolerated.
c. Prescribe NSAIDs, limited activities, and warm compresses to the scrotum.
d. Refer the adolescent immediately to a pediatric urologist or surgeon.
ANS: D
These symptoms are indicative of testicular torsion. Testicular torsion causes a sudden onset
of unilateral pain and is distinguished from epididymitis when elevation of the scrotum causes
an increase in pain (Phren’s sign). It is a surgical emergency and should warrant immediate
referral. Epididymitis is caused by infection and requires antibiotics, bed rest, scrotal support,
and ice packs. Testicular appendix torsion is self-limited and can be managed with NSAIDs,
bed rest or limited activities, and warm compresses.