Pediatric Genitourinary System Examination

The pediatric genitourinary (GU) system includes the kidneys, ureters, bladder, urethra and genital organs. In the emergency department, the focus is on identifying serious pathology (e.g. UTI with sepsis, obstruction, testicular torsion, acute kidney injury) while maintaining sensitivity, privacy and safeguarding.

History

Take history from the caregiver (and age-appropriate child), including:

Dysuria (painful urination), frequency, urgency, incontinence or daytime wetting.
Nocturnal enuresis, new onset bedwetting after being dry.
Haematuria (red/brown urine), cloudy or foul-smelling urine.
Abdominal, flank, suprapubic, scrotal or vulval pain.
Fever, vomiting, poor feeding, weight loss, oedema or reduced urine output.
Previous UTIs, kidney disease, congenital renal or urinary anomalies.
Medication use (especially nephrotoxic drugs), recent dehydration or diarrhoea.
Concerns for trauma or possible sexual abuse (handle with great care and follow local protocols).

Physical Examination

Always explain each step and preserve the child’s privacy and dignity. Have a chaperone present where appropriate.

General & Abdominal Examination

Overall appearance: well vs toxic/ill, hydration status, oedema (periorbital, peripheral).
Vital signs: fever, tachycardia, blood pressure (for nephritic/nephrotic, AKI), respiratory rate.
Abdomen: distension, tenderness (suprapubic, flank, loin), palpable masses (e.g. enlarged kidneys, bladder).
Costovertebral angle tenderness (CVAT) suggesting pyelonephritis.

Male Examination (Child/Adolescent)

Inspect and palpate gently, with a parent/carer present and appropriate chaperone:

External genitalia: position of urethral meatus (hypospadias/epispadias), phimosis, balanitis, discharge, skin changes or bruising.
Scrotum: size, symmetry, swelling, erythema, tenderness, transillumination (hydrocele).
Testes: ensure both are descended, assess size, consistency and tenderness.
Acute scrotal pain: compare lie of both testes, check for high-riding or horizontally lying testis, absent cremasteric reflex → suspect torsion.
Inguinal region: hernias, lymphadenopathy, signs of trauma.

Digital rectal examination is rarely needed in the ED in children and should only be done on clear indication and by senior staff, following local policy.

Female Examination (Child/Adolescent)

In most pediatric ED cases, only an external genital examination is required:

Inspect vulva and perineum: erythema, discharge, ulcers, adhesions, oedema, trauma or bruising.
Observe urethral meatus for discharge, bleeding or prolapse.
Look for labial adhesions, signs of vulvovaginitis, foreign body or dermatitis.

Internal, bimanual or speculum examinations are rare in children and should only be performed in specialist settings (e.g. gynaecology/forensic, under sedation or anaesthesia if necessary) and always according to safeguarding and consent policies.

Pediatric GU Red Flags in the ED

These findings should prompt urgent senior review and often admission:

            Acute scrotal pain with high-riding testis, absent cremasteric reflex or severe tenderness → suspect testicular torsion.
Severe abdominal/flank pain with vomiting and fever → possible obstructive uropathy or pyelonephritis with sepsis.
Visible haematuria, especially with trauma, clot retention, or associated shock.
Oliguria/anuria, generalised oedema, hypertension, or severe electrolyte derangement (AKI or nephritic/nephrotic syndrome).
Palpable abdominal mass (e.g. enlarged kidneys, possible tumour) or grossly distended bladder.
Signs concerning for sexual abuse or non-accidental injury – follow local safeguarding pathways immediately.
Very young infants (<3 months) with fever and suspected UTI.

        

Quick Pediatric GU Algorithm for the ED

Initial Assessment
- ABCDE and overall impression (well vs septic / shocked).
- Check vital signs, hydration, urine output.
Define the Main Complaint
- Dysuria / frequency / fever → suspect UTI.
- Flank pain / fever → pyelonephritis, obstruction.
- Oedema, haematuria, hypertension → nephritic/nephrotic or AKI.
- Acute scrotal or vulval pain/swelling → torsion, hernia, infection, trauma.
Look for Red Flags
- If present → urgent senior review, early antibiotics/fluids/imaging, consider admission.
- If absent and child well → treat, arrange follow-up, give safety net advice.
Investigations (as indicated)
- Urinalysis ± urine culture.
- U&E, creatinine, FBC, CRP, albumin (for nephrotic/nephritic, AKI).
- Renal/bladder ultrasound for obstruction, hydronephrosis, structural anomalies.
Disposition
- Admit for red flags, systemic illness, young infants or unreliable follow-up.
- Discharge stable children with clear diagnosis, treatment plan and safety-netting.

Diagnostic Tests

Common investigations in pediatric GU presentations:

Urinalysis: leukocytes, nitrites, blood, protein, glucose.
Urine culture: to confirm and guide treatment of UTI.
Blood tests: U&E, creatinine, urea, FBC, CRP/ESR, albumin, lipids.
Imaging: renal and bladder ultrasound; further imaging (MCUG, DMSA etc.) usually arranged via specialists.

Table 1: Pediatric Urinary Tract Infection (UTI)

Clinical Features	Possible Causes
Fever, irritability, poor feeding (especially in infants)	Bacterial infection of the urinary tract (often ascending)
Frequent urination, urgency, pain or discomfort during urination	Escherichia coli (E. coli) or other Gram-negative bacteria
Cloudy, foul-smelling, or bloody urine	Ascending infection from the urethra, cystitis or pyelonephritis
Abdominal or flank pain	Upper tract involvement or urinary stasis/structural abnormality

Table 2: Pediatric Hydronephrosis

Clinical Features	Possible Causes
Flank or abdominal pain	Obstruction of the urinary tract (UPJ obstruction, stones, posterior urethral valves)
Unilateral or bilateral swelling of the kidney on ultrasound	Ureteral obstruction or vesicoureteral reflux
Recurrent urinary tract infections	Backflow of urine due to vesicoureteral reflux or obstruction
Feeding difficulties, poor weight gain (especially in infants)	Congenital structural abnormalities of the urinary tract

Table 3: Nephritic Syndrome vs Nephrotic Syndrome

Feature	Nephritic Syndrome	Nephrotic Syndrome
Urine Protein	Usually mild–moderate proteinuria	Heavy proteinuria (>3.5 g/24h equivalent)
Urine Blood	Common; microscopic or macroscopic haematuria	Less common; may be absent or minimal
Oedema	Present but often less severe	Marked, generalised oedema (periorbital, peripheral, ascites)
Blood Pressure	Frequently elevated (hypertension)	May be normal or mildly elevated
Typical Age / Presentation	Often school-aged children with haematuria and hypertension	Often preschool children with heavy proteinuria and oedema

Related Endocrine Conditions Affecting Fluid & GU Status

Some endocrine disorders can present with GU-related symptoms such as hypertension, fluid retention or electrolyte abnormalities.

Table 4: Cushing's Syndrome

Clinical Features	Possible Causes
Weight gain, especially central obesity	Excess cortisol production (endogenous or exogenous)
Facial rounding (moon face), dorsal fat pad (buffalo hump)	Adrenal or pituitary tumours; prolonged corticosteroid therapy
Thinning skin, easy bruising, slow wound healing	Chronic glucocorticoid excess
High blood pressure and high blood sugar	Metabolic effects of excess cortisol

Table 5: Addison's Disease

Clinical Features	Possible Causes
Extreme fatigue, weakness	Primary adrenal insufficiency (autoimmune, infection, genetic)
Hyperpigmentation (skin darkening)	Increased ACTH due to adrenal failure
Weight loss, loss of appetite	Chronic cortisol and aldosterone deficiency
Low blood pressure, salt craving, possible hyponatraemia/hyperkalaemia	Reduced cortisol and aldosterone production

Conclusion

The genitourinary examination in pediatric patients is a key component of ED assessment. By taking a careful history, performing a focused but sensitive examination, watching for red flags, and using targeted investigations, clinicians can identify and manage GU conditions effectively and escalate early when serious disease is suspected.