Even in an adult-focused practice, APPs field pediatric questions — from worried parents, from primary care, and in the ER. This chapter covers the common presentations and the few genuine can't-miss items.
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Even in an
adult-focused practice, APPs field pediatric questions — from
worried parents, from primary care, and in the ER. This chapter
covers the common presentations and the few genuine can't-miss items.
Complex pediatric pathology should be referred to pediatric urology,
but you must be able to recognize what is urgent and what can wait.
Pediatric red flags
Acute scrotal pain in a boy
= testicular torsion until proven otherwise — an emergency
(Chapter 2). Neonatal torsion also occurs and presents as a hard,
discolored, fixed scrotum.
A febrile UTI in an infant
or young child warrants evaluation for vesicoureteral reflux and
anatomic abnormalities — it is not just a UTI.
Antenatal hydronephrosis
needs structured postnatal follow-up — do not assume someone
else arranged it.
A palpable abdominal mass in
an infant (Wilms tumor, neuroblastoma, multicystic dysplastic
kidney) requires urgent imaging.
A newborn who has not voided within 24–48 hours of birth
needs evaluation — think posterior urethral valves in a boy.
16.1 Common outpatient topics
Topic
Practical points
Cryptorchidism (undescended testis)
Refer for orchiopexy if the testis has not descended by ~6 months
corrected age — spontaneous descent after that is rare.
Orchiopexy reduces the risk of infertility and torsion and makes
the testis examinable (it does NOT fully eliminate the elevated
cancer risk, which persists — counsel on self-exam). A
NON-palpable testis requires evaluation (laparoscopy); bilateral
non-palpable testes in a newborn is a possible DSD/endocrine
emergency — check karyotype and 17-OHP
Retractile testis
A testis that can be brought into the scrotum and stays there —
a normal variant with a brisk cremasteric reflex. Follow it,
because a minority ascend and later require orchiopexy
Hypospadias
Ventral urethral meatus, ventral curvature (chordee), and a
dorsal hooded foreskin. DO NOT CIRCUMCISE before repair — the
foreskin is the surgeon's graft material. Refer. Hypospadias with
an undescended testis raises the question of a disorder of sexual
development
Phimosis and physiologic adhesions
A non-retractile foreskin is NORMAL in young boys (only ~10% are
retractile at age 1; most are by puberty). Do NOT forcibly
retract — this causes scarring and true phimosis. Topical
steroid (betamethasone) plus gentle stretching resolves most true
phimosis without surgery
Hydrocele (communicating)
Common in infants due to a patent processus vaginalis; waxes and
wanes in size. Most resolve by 12–24 months. Repair if
persistent beyond ~2 years or if a hernia is present
Nocturnal enuresis
Bedwetting is common and usually benign — 15% of 5-year-olds,
with ~15% resolving spontaneously each year. First treat
constipation and bladder/bowel dysfunction. Then: motivational
therapy, an enuresis ALARM (the most effective long-term
therapy), and desmopressin for short-term needs (sleepovers,
camp). Never shame the child. Daytime wetting is a different
problem and warrants evaluation
Vesicoureteral reflux (VUR)
Retrograde flow of urine from bladder to kidney; graded I–V.
Found after a febrile UTI on VCUG. Managed by grade and by
whether infections recur: observation, continuous antibiotic
prophylaxis, or surgery (ureteral reimplantation or endoscopic
injection). The single most important intervention is treating
bowel and bladder dysfunction — it drives both the reflux and
the infections
Labial adhesions
Common in prepubertal girls; usually asymptomatic and resolve at
puberty. Topical estrogen if symptomatic; avoid forcible
separation
16.2 Pediatric UTI
Symptoms
are nonspecific in infants: fever without a source,
irritability, poor feeding, vomiting, jaundice, and failure to
thrive. Any infant with an unexplained fever needs a urine sample.
Collect
properly: a catheterized or suprapubic specimen is required for
diagnosis in a non-toilet-trained child. BAG specimens are
unreliable — a positive bag culture is contamination until proven
otherwise and should never be used to diagnose a UTI. Use a bag only
to rule OUT infection.
Image
after a first febrile UTI: renal and bladder ultrasound for all.
VCUG if the ultrasound is abnormal, if the infection is atypical
(non-E. coli, sepsis, poor response), or if febrile UTIs recur.
Always
ask about bowel habits. Constipation is the most common and most
treatable contributor to pediatric UTIs and voiding dysfunction, and
it is missed constantly.
16.3 Posterior urethral valves (PUV) — the one
you must not miss
Obstructing
membranous folds in the posterior urethra of a MALE infant — the
most common cause of lower urinary tract obstruction in boys, and a
leading pediatric cause of end-stage renal disease.
Presentation:
antenatal hydronephrosis with a thick-walled bladder and
oligohydramnios; or a newborn boy with a palpable bladder, a
weak/dribbling urinary stream, urosepsis, or renal failure.
Act:
drain the bladder (a small feeding tube), confirm with VCUG (a
dilated posterior urethra is the classic finding), stabilize the
electrolytes and renal function, and refer urgently for valve
ablation. Long-term renal and bladder dysfunction persist even after
successful ablation — these children need lifelong follow-up.
Clinical Pathway
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Even in an adult-focused practice, APPs field pediatric questions — from worried parents, from primary care, and in the ER. Complex pediatric pathology goes to pediatric urology, but you must be able to recognize what is urgent and what can wait.
Run this list first on every pediatric call. These are the ones that cannot wait.
Select a box to open its teaching details.
The five red flags
Acute scrotal pain in a boy
A febrile UTI in an infant or young child
Antenatal hydronephrosis
A palpable abdominal mass in an infant
A newborn who has not voided within 24-48 hours
Ch 16 — pediatric red flags
Time-critical
Also recognize
Neonatal torsion also occurs — it presents as a hard, discolored, fixed scrotum
Action
Treat as an emergency (Chapter 2)
Ch 16 — pediatric red flags
Time-critical
Why
Warrants evaluation for vesicoureteral reflux and anatomic abnormalities
Ch 16 — pediatric red flags
Time-critical
Pitfalls
Do not assume someone else arranged it. Antenatal hydronephrosis needs structured postnatal follow-up — verify it exists.
Ch 16 — pediatric red flags
Time-critical
Consider
Wilms tumor
Neuroblastoma
Multicystic dysplastic kidney
Action
Urgent imaging
Ch 16 — pediatric red flags
Time-critical
Threshold
Has not voided within 24-48 hours of birth
Think
Posterior urethral valves in a boy — see the PUV track
Ch 16 — pediatric red flags
The one you must not miss — the most common cause of lower urinary tract obstruction in boys and a leading pediatric cause of end-stage renal disease.
Select a box to open its teaching details.
Time-critical
What it is
Obstructing membranous folds in the posterior urethra of a MALE infant
The most common cause of lower urinary tract obstruction in boys
A leading pediatric cause of end-stage renal disease
Ch 16.3 — posterior urethral valves
Time-critical
Antenatal
Antenatal hydronephrosis with a thick-walled bladder
Oligohydramnios
Newborn boy
Palpable bladder
Weak/dribbling urinary stream
Urosepsis
Renal failure
Ch 16.3 — presentation
Time-critical
Act
Drain the bladder — a small feeding tube
Ch 16.3 — act
What you are looking for
A dilated posterior urethra is the classic finding
Ch 16.3 — act
Time-critical
Act
Stabilize the electrolytes and renal function
Ch 16.3 — act
Time-critical
Act
Refer urgently for valve ablation
Ch 16.3 — act
What to counsel
Long-term renal and bladder dysfunction persist even after successful ablation — these children need lifelong follow-up.
Pitfalls
Do not let the family (or the chart) treat successful valve ablation as a cure.
Ch 16.3 — act
What to do — and specifically what NOT to do — for the questions parents actually bring in.
Select a box to open its teaching details.
The common topics
Cryptorchidism and retractile testis
Hypospadias
Phimosis and physiologic adhesions
Communicating hydrocele
Nocturnal enuresis
Vesicoureteral reflux
Labial adhesions
Ch 16.1 — common outpatient topics
Is the testis down, retractile, or non-palpable?
Timing
Refer if not descended by ~6 months corrected age
What orchiopexy does
Reduces the risk of infertility and torsion
Makes the testis examinable
Pitfalls
Orchiopexy does NOT fully eliminate the elevated cancer risk, which persists — counsel on self-exam.
Ch 16.1 — cryptorchidism
Features
A normal variant with a brisk cremasteric reflex
Why follow it
A minority ascend and later require orchiopexy
Ch 16.1 — retractile testis
Time-critical
Unilateral non-palpable
Requires evaluation — laparoscopy
Bilateral non-palpable in a newborn
A possible DSD/endocrine emergency
Check karyotype and 17-OHP
Ch 16.1 — cryptorchidism
Time-critical
Recognize
Ventral urethral meatus
Ventral curvature (chordee)
Dorsal hooded foreskin
Pitfalls
DO NOT CIRCUMCISE before repair — the foreskin is the surgeon's graft material. Refer.
Hypospadias with an undescended testis raises the question of a disorder of sexual development.
Ch 16.1 — hypospadias
The numbers
Only ~10% are retractile at age 1
Most are by puberty
For true phimosis
Topical steroid (betamethasone) plus gentle stretching resolves most true phimosis without surgery
Pitfalls
Do NOT forcibly retract — this causes scarring and true phimosis.
Ch 16.1 — phimosis and physiologic adhesions
Why it happens
Common in infants due to a patent processus vaginalis
When to repair
Persistent beyond ~2 years, or
If a hernia is present
Ch 16.1 — hydrocele (communicating)
The numbers
15% of 5-year-olds
~15% resolving spontaneously each year
Sequence
First treat constipation and bladder/bowel dysfunction
Then: motivational therapy
An enuresis ALARM — the most effective long-term therapy
Desmopressin for short-term needs (sleepovers, camp)
Pitfalls
Never shame the child.
Daytime wetting is a different problem and warrants evaluation.
Ch 16.1 — nocturnal enuresis
What it is
Retrograde flow of urine from bladder to kidney; graded I-V
Found after a febrile UTI on VCUG
Management options
Observation
Continuous antibiotic prophylaxis
Surgery — ureteral reimplantation or endoscopic injection
The highest-yield intervention
Treating bowel and bladder dysfunction — it drives both the reflux and the infections
Ch 16.1 — vesicoureteral reflux
Management
Usually asymptomatic and resolve at puberty
Topical estrogen if symptomatic
Pitfalls
Avoid forcible separation.
Ch 16.1 — labial adhesions
Nonspecific symptoms, a specimen that must be collected properly, and the constipation question that is missed constantly.
Select a box to open its teaching details.
Nonspecific symptoms
Fever without a source
Irritability
Poor feeding
Vomiting
Jaundice
Failure to thrive
Rule
Any infant with an unexplained fever needs a urine sample.
Ch 16.2 — pediatric UTI
Time-critical
Required for diagnosis
A catheterized or suprapubic specimen in a non-toilet-trained child
Pitfalls
BAG specimens are unreliable — a positive bag culture is contamination until proven otherwise and should never be used to diagnose a UTI.
Use a bag only to rule OUT infection.
Ch 16.2 — collect properly
Order
Renal and bladder ultrasound for all after a first febrile UTI
Ch 16.2 — image after a first febrile UTI
Does this child also need a VCUG?
VCUG if
The ultrasound is abnormal
The infection is atypical — non-E. coli, sepsis, poor response
Febrile UTIs recur
Ch 16.2 — image after a first febrile UTI
Rule
VCUG is reserved for the three named triggers — an abnormal ultrasound, an atypical infection, or recurrent febrile UTIs
Ch 16.2 — image after a first febrile UTI
Time-critical
Why
Constipation is the most common and most treatable contributor to pediatric UTIs and voiding dysfunction, and it is missed constantly.
Ch 16.2 — always ask about bowel habits
Why it works
In VUR, treating bowel and bladder dysfunction is the single most important intervention — it drives both the reflux and the infections