Summer Break

PediatricEducation.org is taking a summer break. The next case will be published in on July10. In the meantime, please take a look at the different Differential Diagnoses, Symptom and Disease Cases listed at the top of the page.

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What Causes Urinary Hesitancy?

Patient Presentation
A pediatrician asked his colleague for help with considering a differential diagnosis for a college age male who presented with true urinary hesitancy for ~2 weeks. “It’s just not that common a problem in pediatrics,” the pediatrician noted. “The patient has never had any urinary or bowel problems previously, denies dysuria or other pain, or fever. He says he has a normal stream, volume and urinates 6-8 times/day. He denies getting up at night to void. He also denies any bowel problems nor any neurological issues like issues with sensation or problems walking. He also denies any sexual activity for several months,” the pediatrician related to his colleague. “He just says that he wants to void and can’t seem to start his stream in a reasonable amount of time,” the pediatrician said. The second pediatrician agreed that it was not a common problem and asked some more questions about the potential for an occult malignancy or soft neurological signs for a neurological problem which the attending pediatrician said that the patient denied. “I guess I would do a urinalysis and screen him for sexually transmitted infections today and then consult urology. They obviously see this problem more than us and maybe the young man needs to have urodynamics testing or even have a cystoscopy performed,” the colleague stated. “In the meantime you can also have him keep a symptom diary so that you or the urologist can have a better idea of his bowel and bladder patterns,” the colleague also offered.

Discussion
Hesitancy” denotes difficulty in initiating voiding when the child is ready to void,” according to the International Children’s Continence Society. It is not seen that often in pediatrics in isolation, but is commonly associated with other symptoms such as dysuria, frequency, abdominal or anal pain which may indicate common problems such as a urinary tract infection, vaginal/perineal irritation, or constipation. Communication problems can also confound the accuracy of the history as patients and families can have a difficult time describing the urinary problem they are experiencing or may be embarrassed to fully communicate their concerns. Symptom diaries are often helpful to more accurately discern the frequency, and pattern of the problem, along with other concurrent symptoms. Some patients are more comfortable writing about the problem than expressing it verbally and diaries can sometimes assist. Testing for common problems usually begins the evaluation, but consultation with an urologist or another specialist may be necessary.

Learning Point
One of the classic causes of urinary hesitancy is benign prostatic hypertrophy but this is not a common cause in the pediatric and young adult age group. Another cause is medications, but as this age group generally takes fewer medications, drugs are also a less common cause but should be considered in the differential diagnosis.

The differential diagnosis of urinary hesitancy in children and teenagers includes:

  • Obstruction
    • Direct
      • Foreign body
      • Malignancy
      • Prostate
    • Indirect
      • Bowel bladder dysfunction
      • Constipation
      • Pregnancy
      • Abdominal/pelvic malignancy
  • Neurologic/Muscular
    • Bladder neck obstruction
    • Dysfunctional voiding
    • Detrusor urethral sphincter dyssynergy
    • Dysautonomia
    • CNS space occupying lesions – abscess, malignancy
  • Drugs – antidepressants and others which may cause urinary retention
  • Other
    • Sexually transmitted infections
    • Behavioral including abuse
    • Situational – public restrooms

Questions for Further Discussion
1. What are indications for referral to an urologist?
2. What is the difference between dysfunctional voiding and detrusor urethral sphincter dyssynergy?

Related Cases

    Symptom/Presentation: Urine

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Urine and Urination and Bladder Diseases.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Paner GP, Zehnder P, Amin AM, Husain AN, Desai MM. Urothelial neoplasms of the urinary bladder occurring in young adult and pediatric patients: a comprehensive review of literature with implications for patient management. Adv Anat Pathol. 2011 Jan;18(1):79-89.

Glassberg KI, Combs AJ, Horowitz M. Nonneurogenic voiding disorders in children and adolescents: clinical and videourodynamic findings in 4 specific conditions. J Urol. 2010 Nov;184(5):2123-7.

Austin PF, Bauer SB, Bower W, et.al. The standardization of terminology of lower urinary tract function in children and adolescents: Update report from the standardization committee of the International Children’s Continence Society. Neurourol Urodyn. 2016 Apr;35(4):471-81.

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

What are Indications for Continuous Positive Airway Pressure (CPAP)?

Patient Presentation
A 6-year-old male came to clinic with rhinitis and coughing with a fever for 2-3 days. The maximum temperature was 101°F. He was not eating as much and was more fatigued. He denied specific pain. His mother was more concerned because he’s “making lots of loud sounds and snoring at night” also. She stated that he always seemed to be a noisy sleeper and his snoring got worse if he had an upper respiratory tract infection. She denied paused breathing but could not further characterize the sounds or snoring. She denied daytime fatigue when he was otherwise well, but was concerned because her husband had recently started to use a breathing machine at night for “his own snoring and stopping breathing.” The past medical history showed a well child who was obese. The family history also showed obesity and lipid abnormalities. The review of systems was otherwise negative.

The pertinent physical exam showed a tired male with normal temperature, respiratory rate of 22/minute, heart rate of 88 beats/minute and a body mass index of 28. HEENT showed clear rhinorrhea, +3 tonsils with a smaller midface/oropharynx without erythema or exudate, and tympanic membranes were normal. His lungs had transmitted upper airway noises but no adventitial breath sounds. The rest of his examination was normal.

The diagnosis of an upper respiratory tract infection was made. After discussing the acute infection, the pediatrician discussed the possibility of obstructive sleep apnea and referred the child to an otolaryngologist. A sleep study was performed showing obstructive sleep apnea and the child underwent tonsillectomy and adenoidectomy with marked improvement in his snoring even during acute illnesses. Life style interventions for obesity were also being worked on by the family.

Discussion
Obstructive sleep apnea syndrome (OSAS) is defined as a “disorder of breathing during sleep characterized by prolonged partial upper airway obstruction and/or intermittent complete obstruction (obstructive apnea) that disrupts normal ventilation during sleep and normal sleep patterns.” It is different than primary snoring which is snoring without apnea, sleep arousals, or problems with gas exchange.
OSAS symptoms include snoring (often with snorts, gasps or pauses), disturbed sleep (often frequent arousals) and daytime neurobehavioral problems. Sleepiness during the day can occur but is less common in children. Risk factors include black race, obesity, adenotonsillar hypertrophy, craniofacial abnormalities, neuromuscular disorders, or family history of disordered breathing.

OSAS occurs in all ages and is most likely under diagnosed with a 2% prevalence rate. Primary snoring has a prevalence of 3-12%. Problems of untreated OSAS include failure to thrive, cor pulmonale including pulmonary and systemic hypertension, and cognitive and behavioral problems. The gold standard for diagnosis is overnight sleep study (polysomnography).

In addition to lifestyle issues such as avoiding tobacco smoke, air pollutants and allergens and treatment of rhinitis and weight loss strategies in some patients, treatment of OSAS for children usually begins with tonsillectomy and/or adenoidectomy. While this can treat many patients, others still will have OSAS. Noninvasive ventilation such as continuous positive airway pressure (CPAP) may be the next step for some children. CPAP devices use a small turbine to create increased pressure that is delivered to the upper airway by a fitted mask. Additional options include other oral-facial surgeries, orthodontic treatments or dental appliances. Drug treatment with nasal steroids and/or montelukast have also been used.

Learning Point
Indications for non-invasive ventilation including CPAP consist of:

  • For neonates, infants and pediatric patients
    • Asthma
    • Bronchiolitis
    • Obstructive sleep apnea syndrome
    • Pneumonia
    • Muscle fatigue, impending of respiratory muscles
    • Myopathies
    • Ventilator management
      • Good respiratory drive but still needing minimal respiratory support
      • Weaning
    • Lung collapse prevention
  • For adults
    • Obstructive sleep apnea syndrome
    • Chronic obstructive pulmonary disease with exacerbation
    • Acute congestive heart failure with pulmonary edema
    • Acute lung injury
    • Neuromuscular disorders
    • Pneumonia
    • Ventilator weaning

Absolute and relative contraindications include unstable cardiopulmonary status or need for continuous or near continuous ventilator treatment, inability to protect the airway including reduced consciousness or excessive secretions, air trapping or air leak diseases, problems with facial structures including trauma, burns, recent surgery or esophageal or gastric surgery, patients who are very anxious or uncooperative.

Questions for Further Discussion
1. What is the difference between CPAP and BiPAP?
2. What are your local resources for sleep studies?
3. What history and physical examination findings are there for OSAS?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Sleep Apnea and Snoring.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Praud JP, Dorion D. Obstructive sleep disordered breathing in children: beyond adenotonsillectomy. Pediatr Pulmonol. 2008 Sep;43(9):837-43.

Marcus CL, Brooks LJ, Draper KA, et.al.; American Academy of Pediatrics. Diagnosis and management of childhood obstructive sleep apnea syndrome. Pediatrics. 2012 Sep;130(3):576-84.

Sweet DG, Carnielli V, Greisen G, et.al.; European Association of Perinatal Medicine. European consensus guidelines on the management of neonatal respiratory distress syndrome in preterm infants–2013 update. Neonatology. 2013;103(4):353-68.

Gonzalez Mangado N, Troncoso Acevedo MF2, Gomez Garcia T. Home ventilation therapy in obstructive sleep apnea-hypopnea syndrome. Arch Bronconeumol. 2014 Dec;50(12):528-34.

Poobani, SK. Noninvasive Ventilation Procedures. eMedicine. Available from the Internet at:
http://emedicine.medscape.com/article/1417959-overview#a3 (rev. 12/21/2015, cited 4/5/17)

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital