Goals of Treatment Girls have some specific anatomic findings that may bring them in for evaluation The key to treatment is differentiating the few true emergencies from the more benign presentations Clinical Recognition The one anatomic urologic finding in a female that should cause alarm is the presence of a vaginal mass This may represent vaginal rhabdomyosarcoma The patient with a vaginal mass needs immediate referral to and evaluation by urology and oncology Some more benign vaginal “masses” may include vaginal cysts, Gartner duct cysts, Bartholin cysts, and paraurethral cysts These cysts may represent isolated findings, or could represent an ectopic ureter draining into the introitus Additionally, a pelvic or vaginal mass may represent hydrometrocolpos in a patient with vaginal agenesis, atresia, stenosis, or imperforate hymen Other female urologic issues that may present to the ER are urethral prolapse and labial adhesions Clinical Assessment If there is concern for a lower abdominal or pelvic mass on history or physical examination, a renal bladder ultrasound and a pelvic ultrasound should be performed The pelvic ultrasound will help to further define the vaginal mass, and a renal bladder ultrasound will help determine the etiology (duplicated kidney, absent kidney, hydroureteronephrosis) Urethral prolapse typically presents in African-American girls aged ∼6 to 11 years (but can occur at any time from birth to ∼11 years old) This entity often presents with spotting of blood in the underwear, but is otherwise asymptomatic On examination, a red ring of prolapsed mucosa surrounding the urethra is noticeable The introitus must be seen to be separate and uninvolved Labial adhesions appear as a “median raphe” formed by the two edges of labia minora Most commonly they begin at the posterior fourchette and extend toward the clitoris, with a pinpoint opening for urine to come out Symptoms may include UTI symptoms, dysuria, or spraying with urination Management For urethral prolapse, observation alone is often sufficient, but can be combined with estrogen cream and/or sitz baths For recurrent cases, surgical excision of the prolapsed mucosa may prevent further episodes For labial adhesions, observation alone is reasonable for the asymptomatic child, as they typically resolve once the child reaches puberty and the tissues become estrogenized If the girl is symptomatic, or the parents are concerned, the adhesions can be treated with topical estrogen cream (Premarin 0.1% twice daily for to weeks) followed by petroleum jelly at bedtime to keep the labia from refusing Side effects may include hyperpigmentation and breast tenderness, which resolve after the cream is discontinued Alternatively, after application of a topical anesthetic cream, the adhesions can be bluntly divided with a finger or a probe, and then copious petroleum jelly should be applied up to three times a day (or with every diaper change) for several months However, adhesions can recur RENAL COLIC/NEPHROLITHIASIS CLINICAL PEARLS AND PITFALLS A febrile obstructing stone is a true urologic emergency, and can result in significant morbidity and even mortality, if not appropriately diagnosed in an expeditious manner Goals of Treatment Determining when nephrolithiasis requires emergent treatment versus when supportive care in conjunction with medical expulsion therapy is indicated is of key importance The primary goal in the acute setting is diagnosing obstruction, when it is present, and providing pain control, nausea control, hydration, and education Clinical Recognition A kidney stone becomes a true emergency when it is associated with a fever, or if there is an obstructing stone in a solitary kidney Aside from these two settings, management rests on symptom control and stone expulsion Triage Considerations Fever in the setting of an obstructive stone is a medical and surgical emergency, and without timely treatment, a patient can progress to sepsis, with the potential for rapid decompensation Moreover, obstruction in a solitary kidney can lead to acute renal failure Patients with two functional kidneys who present with pain and/or nausea due to stones and without fever require only symptomatic treatment Management A patient presenting with flank pain with or without the presence of hematuria should be evaluated for a kidney stone After a history and physical examination to evaluate for a solitary kidney or chronic kidney disease and for the presence of a fever, an ultrasound is the first-line imaging that should be obtained Initial medical management should include hydration (this should be IV until there is no chance that the child will have to undergo urgent surgical management), and pain control with narcotics and nonsteroidal anti-inflammatory medications, if there is no evidence of renal dysfunction If a stone is suspected and the ultrasound is abnormal but does not show a stone specifically, a low-radiation noncontrast CT scan can be obtained; however this is not required The patient can be treated with medical expulsion therapy alone, including pain medication and tamsulosin If the patient requires surgical decompression, there are three modalities available: percutaneous nephrostomy tube placement or retrograde placement of a ureteral stent, or extracorporeal shock wave lithotripsy (ESWL) ACUTE URINARY RETENTION CLINICAL PEARLS AND PITFALLS A seemingly benign presentation may have an underlying significant problem A perforated bladder augmentation can be life threatening, and must be diagnosed and treated on an urgent basis Urinary retention in a small child may be the only presenting sign of a rhabdomyosarcoma Background A patient with acute urinary retention is unable to empty the bladder even though it is full The cause may be bladder outlet obstruction, or may be due to lack of bladder function, as a result of a neurologic problem, or may be volitional Goals of Treatment Recognize the problem, and facilitate drainage of the bladder Clinical Recognition Determining the underlying etiology of the urinary retention is of key importance, as is determining who is at risk for complicating factors from experiencing retention In newborns and infants, bladder outlet obstruction due to posterior urethral valves or obstructing ureteroceles must be identified In older children, posterior urethral valves must remain on the differential, as postoperative retention due to narcotics, fear of urination due to recent urethral manipulation, and children with severe constipation An important uncommon etiology that cannot be missed is that of augmented bladders that cannot be catheterized, as these are at risk for perforation Also, the practitioner should question the seemingly “simple” urinary retention with no obvious cause: rhabdomyosarcoma of the bladder or prostate may present with retention as the sole symptom Triage Considerations It is essential to determine who is sick, or who can get sick very quickly Any patient with a bladder augmentation who is in retention and unable to catheterize is at risk for bladder augment perforation—which becomes an emergent surgical matter Clinical Assessment Diagnosis begins with a careful history This will elicit not only medical history, including past surgeries, but also the history of a weak stream or difficulty initiating voiding may offer clues Duration of retention and symptoms experienced are also important in determining the treatment plan Management For the child with voluntary retention, gentle massage of the lower abdomen, combined with a soak in a warm tub, usually leads to spontaneous evacuation of the bladder Rarely does a child’s bladder become so distended, as after an outpatient surgical general anesthetic, that the child is unable to void It should be remembered that a child is able to hold urine voluntarily for longer periods than would be suspected; up to 12 hours is not unusual In order to actively drain the bladder, a catheter must be placed This can be done with a bladder catheter or small feeding tube Once the bladder is drained, a urinalysis and urine culture should be obtained Depending on the history, the catheter should be left indwelling, or can be removed after draining the bladder entirely If a catheter cannot be placed (due to previous surgery, or presence of obstruction or false urethral passage), then drainage via a suprapubic approach must be undertaken This can be performed with a needle if drainage and urine sample are needed alone, or a large tube can be placed with the assistance of interventional radiology or urology ... COLIC/NEPHROLITHIASIS CLINICAL PEARLS AND PITFALLS A febrile obstructing stone is a true urologic emergency, and can result in significant morbidity and even mortality, if not appropriately diagnosed... control, nausea control, hydration, and education Clinical Recognition A kidney stone becomes a true emergency when it is associated with a fever, or if there is an obstructing stone in a solitary... expulsion Triage Considerations Fever in the setting of an obstructive stone is a medical and surgical emergency, and without timely treatment, a patient can progress to sepsis, with the potential for