especially those who are uncircumcised, are nonspecific bacterial infections that can present with frequency, dysuria, and purulent discharge The term urethral syndrome refers to an entity that can be seen in female adolescents, characterized by acute onset of frequency and dysuria with “insignificant” bacterial counts (less than 10,000 colony-forming units per mL) Pyuria is generally, but not absolutely, present Vaginitis is a common cause of the urethral syndrome C trachomatis and N gonorrhoeae are again common culprits Irritative vulvovaginitis (e.g., secondary to poor hygiene or bubble baths) is a relatively common cause of frequency, usually associated with dysuria but not with pyuria Candidal vulvovaginitis presents with similar symptoms, but also with white discharge, and is more common in adolescent females Vaginal foreign bodies in young children also can cause frequency in addition to vaginal discharge Frequency may be secondary to urethral trauma such as straddle injuries, catheterization, masturbation, or sexual abuse As an isolated symptom, frequency would be an atypical presentation of pediatric sexual abuse However, urinary frequency may be seen in association with pertinent history or physical findings (e.g., vulvovaginal infection or genital trauma), which would be suggestive of sexual abuse Pinworms (Enterobius vermicularis ) may occasionally cause frequency in young females Children with pinworm infestation may or may not present with perineal itching Pyuria and dysuria are usually absent Extraurinary System Neurologic Central DI is a deficiency in the hypothalamic production of antidiuretic hormone that leads to inability of the renal system to properly concentrate urine Etiologies such as septo-optic dysplasia and other developmental anomalies present in the neonatal and infancy period However, most causes of central DI are acquired (e.g., head injury, brain tumors) and therefore can present at any age DI is a lifethreatening cause of urinary frequency as lack of access to appropriate hydration leads to hypernatremic dehydration A neurogenic bladder associated with a spinal cord lesion (e.g., tethered cord) may present with urinary frequency, as the patient cannot empty the bladder fully Urine volumes are small but frequent Physical examination may yield associated abnormalities (hairy patches, cutaneous dimples or tracts, lipoma, or bony irregularities), decreased anal tone, lower-extremity weakness, or reflex abnormalities Generally, postvoid residual urine volumes are increased Uninhibited bladder contractions (“unstable bladder” syndrome) occur involuntarily in children who have failed to gain complete voluntary control over the voiding reflex, related to delayed nervous system maturation If the urethral sphincter is relatively weak, urinary frequency associated with urgency and enuresis may result Females may exhibit the so-called “curtsy” sign as the child squats and attempts to prevent leakage by compressing the perineum with the heel of one foot If performed, a screening ultrasound examination would reveal normal (minimal) residual urine volumes With maturity, spontaneous resolution of uninhibited contractions occurs in most cases In children with significant developmental delay or behavioral disorders, the infantile pattern of spontaneous bladder contraction may persist Abdominal Masses in the pelvis (including abdominal tumors, appendicitis, and ovarian torsion) that press on the bladder can cause frequency Generally, these diagnoses cause abdominal pain and/or other symptoms, and physical examination will elicit tenderness Constipation is a common cause of urinary frequency in schoolaged children It results in large fecal masses that cause mass effect with extrinsic bladder pressure, as well as stimulating bladder contraction or inhibiting the full bladder capacity Such frequency may then be small volume excretions There is noted association with constipation and UTI Pregnancy should always be considered as a cause of frequent urination in the adolescent female Metabolic and Endocrinopathies Diabetes mellitus (DM) causing osmotic diuresis from increased glucosuria is an emergent condition causing frequency Typically, new-onset diabetes presents with polydipsia, polyphagia, and polyuria; uncontrolled DM with or without diabetic ketoacidosis can present similarly Be alert for other concerning findings including altered mental status and respiratory changes Hypercalciuria has been reported as a significant noninfectious cause of the “frequency–dysuria syndrome” in pediatric patients Onset of symptoms generally ranges from to 14 years of age Occasionally, hypercalciuria can present in early infancy, where irritability is a hallmark symptom Symptoms often spontaneously resolve within months There may be a positive family history of calcium urolithiasis Dysuria may or may not be present Hematuria (generally microscopic) and/or crystalluria are often seen However, the urinalysis may be normal If the diagnosis is suspected and symptoms persist, studies of urinary calcium excretion and urologic consultation should be considered The salt-losing form of congenital adrenal hyperplasia is a rare but life-threatening cause of frequency Excessive urinary excretion of sodium leads to marked dehydration with hyponatremia Female infants may exhibit virilization of the external genitalia Male infants may demonstrate increased pigmentation of the external genitalia and/or a relatively enlarged phallus Drugs and Toxins Drugs are a relatively common cause of frequency in adolescence Methylxanthines (caffeine, theophylline) and ethanol inhibit the production of antidiuretic hormone In addition to caffeinated drinks (soft drinks, coffee, black teas, energy drinks), chocolate is another source of caffeine Diuretic agents, such as furosemide or hydrochlorothiazide, can cause frequency when ingested other intentionally or accidentally Lithium and vitamin D are also associated with urinary frequency, interfering with renal responsiveness to antidiuretic hormone Many other medications may cause frequency, and a pharmacologic history should be obtained in the child who presents with urinary frequency Psychogenic Frequency may be a presenting symptom of water intoxication leading to polyuria Patients not have nocturia, as enuresis is related to excessive fluid intake The serum sodium and osmolality may be decreased Psychogenic polydipsia is an extremely unusual diagnosis in young children but may present in adolescence Water intoxication secondary to Munchausen syndrome by proxy, an unusual presentation of abuse in the younger child, is also a consideration The “extraordinary urinary frequency syndrome” can cause urinary frequency in pediatric patients Average age of onset is years (with a range of about to 11 years) Daytime frequency occurs as often as every minutes Nocturia is present in about half the cases but usually occurs only about one to two times per night Generally, only reassurance is needed, as this often resolves spontaneously within about months (although in some children, the duration of symptoms can be markedly longer) The etiology is unclear, but often has a psychogenic component, with an apparent “trigger” (school problems, parental death, sibling illness, etc.) identifiable in about half the cases After consultation, a trial of extended-release oxybutynin, behavior modification, and/or biofeedback techniques are therapeutic considerations EVALUATION AND DECISION The primary role of the emergency physician in evaluating the child with urinary frequency is to exclude significant underlying pathology that may result in morbidity, identify treatable conditions, and determine appropriate referral when needed The nature and quality of the urine should be assessed, including color (suggesting dilute or concentrated urine), presence of blood (suggesting nephrolithiasis or intrinsic renal disease), and foul odor (suggestive of an infectious etiology) Additional history should then focus on elucidating the organ system principally involved in the etiology of the urinary frequency (see Table 78.1 ) Infectious causes are heralded by dysuria, fever, or flank pain, or may be suggested with a history of prior UTIs Abdominal pain can signal a primary abdominal etiology (such as severe right lower quadrant pain suggesting appendicitis or severe colicky left lower quadrant pain suggesting ovarian torsion) Questions related to DM should be included in the history (such as polydipsia, polyphagia, weight loss, and family history) The presence or absence of nocturia and enuresis is also an important historical point Neurologic complaints can suggest central DI A thorough stooling history should be obtained to evaluate for constipation, especially in toddler and school-aged children A complete medication and substance use history should be obtained given the varied toxicologic etiologies of urinary frequency The last menstrual period of an adolescent female should be ascertained Perform a complete physical examination, including an accurate blood pressure measurement The child’s growth parameters should be plotted, and the blood pressure should be compared with age-specific normal values to screen for hypertension (see Chapter 37 Hypertension ) Carefully palpate the abdomen for the presence of abdominal masses and/or tenderness, specifically in the lower quadrants Percussion of the flanks should be performed Examine the lumbosacral area closely for anomalies (hairy patches, dimples, tracts, etc.) Special attention should be focused on the function of sacral nerves II to IV (anal wink and sphincter tone) Unless the diagnosis is readily apparent, a rectal examination should be performed, noting tone, tenderness, masses, and the quality and quantity of stool in the rectal vault The external genitalia should always be thoroughly examined, meticulously searching for signs of infection, trauma, or anatomic abnormalities Signs of virilization (in the female) or hyperpigmentation (in the male) should be evaluated A thorough neurologic examination with careful attention to the retinal fundi and visual fields is warranted The laboratory evaluation of urinary frequency begins with a urinalysis An algorithm for interpretation of the urinalysis is shown in Figure 78.1 If cystitis or pyelonephritis is suspected by history, physical and urinalysis, a urine culture should be sent A catheterized specimen should be obtained for a culture in all ... Hypercalciuria has been reported as a significant noninfectious cause of the “frequency–dysuria syndrome” in pediatric patients Onset of symptoms generally ranges from to 14 years of age Occasionally, hypercalciuria... also a consideration The “extraordinary urinary frequency syndrome” can cause urinary frequency in pediatric patients Average age of onset is years (with a range of about to 11 years) Daytime frequency... biofeedback techniques are therapeutic considerations EVALUATION AND DECISION The primary role of the emergency physician in evaluating the child with urinary frequency is to exclude significant underlying