GENITO URINARY PROBLEMS IN

CHILDREN

Satiti Retno Pudjiati

Bagian Ilmu Kesehatan Kulit & Kelamin

Fakultas Kedokteran UGM
Yogyakarta
Introduction

Genitourinary problems in children:

* anatomical abnormalities,
* inflammation non-infections ,
* non-sexual infections,
* sexual infections,
* tumours.
Genitourinary problems in children less
common than in adult, but the diseases
that occurred in adult can occurred also in
children.

This lecture focused on:

•non-sexually acquired genital infection,
•sexually genital infection, and
•sexual abuse.
NON-SEXUALLY ACQUIRED GENITAL
INFECTION IN CHILDREN

The most common non-sexually

acquired genital infections in
children are:
* vulvovaginitis,
* balanitis,
* pinworm,
* scabies,
* molluscum contagiosum,
* fungal infections
vulvovaginitis and balanitis caused by

•streptococcus
•staphylococcus,
•candida,
•shigella,
•foreign bodies,
Vulvovaginitis and balanitis

The most cause of acute vulvovaginitis

and balanitis in prepubertal child are
Group A β-haemolytic streptococcus

Apart from causing the inflammation to

the area genital, the infection could
involve the anal area.
In girls with vulvovaginitis:

•sudden onset
•erythematous,
•swollen,
•painful vulva and vagina,
•thin mucoid discharge.
In boys with balanitis

•acute erythema of the glans

In general, patients with this condition are:

•systemically well
•fever and scarlatiniform rash,
•followed by acral desquamation
•in association with perianal disease, has
been reported.

•In this case, a streptococcal pyogenic

exotoxin was assumted to be produced by
the infective organism..
The infection is easily diagnosed :

•by introital and perianal swabs.

•It is not necessary to insert the swab right

into the vagina, which children usually find
traumatic, particularly when the area is
tender
 The non-infection illness that gave the
sign was similar with bacterial vulvovaginitis
and balanitis were:

•psoriasis,
•dermatitis,
•fixed drug eruption (FDE),
•erythema multiforme.
psoriasis dermatitis

FDE
 Treatment for bacterial vulvovaginitis and
balanitis could be given :

•penicillin
•amoxicillin,
•Cephalosporin
•The concurrent use of topical mupirocin will
help to prevent recurrence.
Pinworm
(enterobiasis vermicularis)

•Pinworm is very well known as a cause of

genital itching in children

•many children will already have been treated by

their parents or their pharmacist before they see
a doctor.
Clinical manifestation:
•Although many children with pinworm
infestation are asymptomatic,

•symptoms are those of perianal and vulval

itching, particularly at night, when the worm
migrate onto the skin to lay eggs.

•An eczematous rash may occur, but the skin

may be normal.

•Vaginal discharge and irritation may also

occur.
Diagnosis may be made by :

*pressing the sticky side of clear tape to the

perianal area first thing in the morning and
then examining the tape under a microscope
for the presence of ova.
Treatment requires:

•oral mebendazole 100 mg, or

• pyrantel pamoat 11 mg/kg up to 1 g.

•A further treatment in 2 weeks is

recommended to kill worms that have hatched
since the first treatment.
 Scabies

* Scabies are caused by Sarcoptes scabiei.

• Bonomo in 1687.
• general population with low socioeconomic
level.
• frequent in school-age children but is
unlikely to
be transmitted in schools.
• Outbreaks are not uncommon in nursing
homes, hospitals, and other institutions.
CLINICAL MANIFESTATION:

• In the current cycle, classic scabies is seen

less frequently.
• Itching is characteristically nocturnal.
• Lesions are symmetrical.
• The hands are often the first area involved;
lesions occur mainly on the finger webs and the
sides of the digits.
•The flexor surfaces of the wrist are commonly
involved, as are the extensor surfaces of the
elbows and the anterior axillary folds.
•Misdiagnosis scabies in infants and young
children is frequent in such cases because of :

- low index of suspicion,

- secondary exzematous changes
suggesting other conditions, and
- atypical distribution to include head,
neck, palms, and soles.
- Vesicles are common.
- Secondary bacterial infection, manifest as
pustules, bullous impetigo, severe
crusting or ecthyma, is frequent.
• Scabies is a great imitator.
• Differential diagnosis includes :

- nearly all pruritic dermatoses, including

- atopic dermatitis,
- contact dermatitis,
- prurigo,
- papular urticaria,
- pyoderma,
- pruritus due to systemic disease,
- insect bite,
- mastocytosis, and
- pediculosis
The diagnosis could be made by :
•typical clinical features, and
•laboratory examination:

- skin scrapings,
- needle extraction of mite,
- epidermal shave biopsy,
- burrow ink test,
- curettage of burrows,
- swab technique with clear cellotape
adhesive, and
- punch biopsy.
 TREATMENT

•The choice of a drug for treatment of

scabies must take into account efficacy and
potential toxicity.
• Many antiscabies were available:

- Lindan cream or lotion,

- Crotamiton, and
- Permethrine.
 Molluscum contagiosum

• caused by Pox virus.

• very common in children.

• The virus is spread in water, and this explains

the predilection for the lower body where the
child sits in the bath. As a result, it is not
uncommon for mollusca to be found on the
genital area, often as part of a more generalized
eruption.
Clinical manifestation

• Sometimes vulval mollusca can be difficult to

differentiate from condyloma acuminate,

•mollusca are generally not considered to be

sexually transmitted in children.
TREATMENT

• In most cases, it is not necessary to

treat genital mollusca.

•extract the viral core from the center,

• Spontaneous resolution invariably

occurs.
Fungal infections

The most Fungal infection that found in child

anogenital area are:

- candidiasis and
- tinea.

When it does occur, it hardly ever has typical

features, and this is often the result of treatment
with topical corticosteroids
Clinical manifestation

Candidiasis Tinea

•Erythematous
•Satelite lesion Central healing
Diagnosis & Treatment

* skin scraping

• topical antifungal including azole; e.g.

- miconazole and
- ketokonazole.
1.SEXUALLY TRANSMITTED DISEASES IN
CHILDREN

•occur as a result of
- intrauterine infections,
- vertical transmission,
- postnatal infection, and
- sexual abuse

* not different with the adult

•STIs that common in the children are:

- sifilis,
- gonorrhea,
- Chlamydia trachomatis infections,
- condylomata acuminata,
- genital herpes simplex virus infection,
- trichomonas vaginalis infection, and
- HIV infection.
Syphilis

• caused by Treponema pallidum.

• systemic infection.
• Infection can be transmitted transplacentally
(congenital syphilis) or postnatally (acquired
syphilis).
• Congenital syphilis is always caused by
maternal syphilis.
• Almost all acquired syphilis in children is
associated with sexual abuse.
Congenital syphilis

• transplacentally  presents either early (< 2 years

of age) or late (> 2 years of age).
• Infant with early congenital syphilis may be
stillborn or present with signs and symptoms at
birth or gradually develop signs and symptoms over
the first few months of life.
• Late congenital syphilis presents with some
characteristic finding such as interstitial keratitis.
Clinical manifestation early: < 2 th
Congenital syphilis
-lesi kulit: terjadi segera, vesikobulosa,
erosi,papuloskuamosa,

Syphilitic pemphigus
 Sifilis kongenital dini

perdarahan mukosa

- anemia hemolitik
- hepatosplenomegali
- SSP
 Sifilis….
Late congenital syphilis > 2 th

-keratitis interstisialis, pubertas, bilateral

Sifilis kongenital lanjut Sifilis….

gigi hutschinson

gigi Mulberry
Acquired syphilis

• almost always transmitted through abuse.

• The Clinical manifestation similar with syphilis
in adult.
• If no treatment, the clinical manifestation
follow with naturally syphilis, these are:
primary syphilis,
secondary syphilis, and
latent syphilis.
Primary syphilis
• The initial hallmark is the chancre.
• seen at the site of contact 10 and 90 days
after an incubation.
• Usually seen on:
- the penis,
- vagina, and
- anus.
- lips and
- breasts.
* The chancre begins as an erythematous
macules which becomes popular and then
ulcerates.
 Secondary syphilis
• Six weeks after development of a chancre,
• generalized T. pallidum dissemination.
•Constitutional symptoms such as fever and
malaise are common.
 Latent syphilis

The stages are devided into :

early latent (< 1 year) and

late latent (> 1 year),
based on the lower level of transmissibility in late
latent syphilis.
Latent syphilis in children has not been well
described.
 Diagnosis Sifilis….

klinis + lab
1. Lab: medan gelap (dark field)  sifilis primer
2, antibodi serum : VDRL (1/16), TPHA
 S sekunder & tersier
•acquired either perinatally, from an infected
mother, or,
•in older children, by intimate contact (almost
always sexual).
•In newborn: conjunctiva and pharynx, caused by
contact from infected cervical secretions of the
mother to mucous membrane of the baby.
• Conjunctivitis is the most common manifestation in
newborn.
• usually presents at 2-5 days of life,
•Complication:
- keratitis,
- iridocyclitis,
- corneal ulceration and perforation
- blindness
Gonococcal infections in older children

• usually local infections (vaginitis, urethritis,

conjunctivitis, pharyngitis, and proctitis).
• Dissemination infections are uncommen but do
occur in preadolescent children, with arthritis
Gonococcal vulvovaginitis
• usually presents as a profuse purulent vaginal
discharge ranging from white, cream or yellow
to green in colour that stains the underwear.
• Pruritus,
• vulval erythema and
• dysuria may also be present.
• Symptoms are usually present for less than a
week (median 3 days).
Gonococcal infections are less frequent in boys,

* urethral discharge associated with urethritis.

* The discharge may be copious or scant,
* penile oedema or
* the testicular swelling of epididymitis.
* Dysuria may also be present.
Diagnosis

•medicolegal implications
•standart culture systems
•Gram-stained smears, EIA tests and DNA
probes should not be used
•Gram-stain smears of speciments can be useful
in clinical practice, and are recommended for
screening,
• they are inadequate for definitive diagnostic
purposes.
Treatment

Penicillin was the of choice until the spread of β-

lactamase-producing N. gonorrhoeae worldwide
precluded this as an initial treatment option.

However, third generation cephalosporins are now

first-line therapy in children
Chlamydia trachomatis
infections

• in neonate usually transmitted from the mother

who infected chlamydial cervicitis.
• transmitted during delivery per vagina.
• The most organ that infected are: conjunctiva,
nasopharynx.
• In older children, infection occur in rectum and
vagina usually caused by sexual abuse.
clinical manifestation

•neonatal conjunctivitis.
•fifth and the twelfth postnatal day.
•mild conjungtival infection with scant
mucoid discharge to severe conjungtivitis with
copious purulent discharge,
•chemosis and pseudomembrane formation.
• The conjungtiva can be very friable and
may bleed when stroked with a swab.
 Pneumonitis
•It is unclear whether chlamydial pneumonitis
develops
(1)from aspiration of infected servical secretions at
delivery,
(2) from transmission down the respiratory and
nasopharynx,
(3) from post natal aspiration of nasopharyngeal
secretions, or
(4) from all three mechanisms.
* Regardless of mechanism, however, a favourite
locate for C. trachomatis infection appears to be the
infant posterior nasopharynx.
Condylomata acuminate

• anogenital warts caused by human

papillomavirus (HPV) infection.
• Most commonly are caused by HPV types 6,
11, 16, and 18, although type 2 is also found
caused by manual transmission.
• The majority of CA in children younger than 3
years is due to vertical transmission during
birth.
• Sexual transmission has been reported to be
up to one in three children older than 3 years old
age, there is suspected sexual abuse.
• Modes of non-sexual transmission include:
(1) hand-genital contact via an infected
carer of the child,
(2) non-sexual intimate behavior, or
(3) inadequate hygiene, for example via
contaminated objects such as a towel
• The incubation period 1.5 to 8 months, with a
peak at 3 months.
• Usually, CA cause no complaints
• CA are usually encountered in
mucocutaneous or intertriginous area

the anogenital region,

the perineum,
on the labia,
around the vaginal entrance,
around the anus and in the rectum
* The warts usually have the shape of
a cauliflower or are stemmed,
flat forms may be encountered.
• They are red, pink, or skin-colourd.
• Subclinical infections may occur in teenagers and
adults.
• Extremely large CA may occur in children with
HIV infection.
 Management

• CA disappear in more than half of the cases

spontaneously after 2 years,

• so a “wait and see” policy is possible.

• Malignant transformation in young children has not

been described.
Genital herpes simplex
virus infection

• HSV type 2 and, type 1<<.

• HSV can transmitted in various ways, such as
intra uterine transmission,
during delivery,
after delivery,
via a sexual contact and
via non-sexual contacts.
In sexual contact, transmission occurs via
close contact with an infected individual, from an
active lesion, mucosa or secretions.
• Direct contact between live virus and the
mucosa or damaged skin is essential for
transmission of infection.

• However, HSV can survive for some time,

for example on a speculum or glass slide or
on plastic and rubber objects for a maximum
of 4 h, but these transmissions are less
common.

• HSV is rapidly inactivated at room

temperature and through drying.
•Incubation period of acquired infection is 4-20 days.
• HSV causes painful vesicular or ulcerating lesions
on the skin or mucosae,
• often with fever.
• In acquired infection in children is usually located
around the mouth or on the fingers.
• Genital HSV infections are rare in children.
Human Immunodeficiency
virus (HIV) infection

•HIV infections in children may occur

after medical intervention such as
administration of infected blood products,
via mother to child transmission,
through intravenous drug abuse and
through sexual contact
• HIV infection in the child has a wide spectrum
ranging from an asymptomatic stage to severe
disease.

• Most children become symptomatic by the

age of 6 years.

• Among symptomatic children, two main

disease patterns are observed:
those with and those without early onset of
Opportunistic infection (OI).
Children who developed an OI early
have a poor outlook and usually do not
survive beyond 2 years of age.
A wide range of symptoms has been described in
HIV infected children. The frequent clinical
syndromes in HIV-infceted children are:
•Neurodevelopmental delay, encephalopathy,
microcephaly
•Recurrent bacterial and viral infections
•Pulmonary lymphoid hyperplasia (PLH), lymphoid
interstitial pneumonitis (LIP) complex
•Lymphadenopathy, hepatosplenomegaly
•Failure to thrive
•Recurrent or chronic diarrhea
•Opportunistic infections
•Hematologic changes (leucopenia, thrombocytopenia,
anemia)
Trichomonas vaginalis infection

•Trichomonas vaginalis (TV) is a flagellated

protozoon.
•The organism of TV can survive for several
hours on wet towels and clothing which have
been used by infected women.
•The organism also appeared to be able to
survive in samples of urine and sperm even after
they had been exposed to air for several hours.
There are several possible explanations for
infections in children.
Contamination of the nose/throat cavity and also
of the vagina may occur during delivery.
 Acquired TV infections are rare before puberty
because the environment in the prepubertal
vagina is poor source of nutrition whereby growth
and colonization are not possible.
A sexual contact between a child and an adult is
suspected if a TV infection is encountered in a
child older than 1 year.
Non-sexual transmission in prepubertal children
is probably very rare because the organism is
highly location specific.
•The period of incubation is 1-4 weeks.
•In adolescents, there may be
vulvovaginitis with purulent discharge,
urethritis and cystitis.
*The infection may be asymptomatic.
*Transient vulvovaginitis is the most probable
complaint in prepubertal children.
 Bacterial vaginitis
•prepubertal girls.
•It is a polymicrobial disorder, whereby various
bacteria such as Gardnerella vaginalis,
anaerobes, Mobilincus species, and Mycoplasma
hominis are present.
•BV is encountered more often in abused than in
non-abused girls.
•It is unclear whether BV can be transmitted
during delivery.
1.SEXUAL ABUSE AND STI

•Child sexual abuse occurs commonly.

• incidence and prevalence are unknown,
• it is estimated that at least once in four girls
and one in ten boys will be molested before
age 16.
• Over 50,000 cases are reported each year
in the united States.
• Statistics from other countries show similar
frequencies of occurrence
Most perpetrators are male and likely to be trusted
by the victim. Some features of family structure are
associated with a small increased risk of child
sexual abuse. These include:

1.Presence of a stepfather
2.Children living without one or both natural
parents
3.Maternal disablement or absence; or
4.Poor or punitive parenting.
Findings that are specific or diagnostic of
child sexual abuse:
•The presence of semen in the vagina, anus or external
genitalia
•Pregnancy
•Positive gonorrhea or syphilis in the absence of perinatal
transmission
•HIV infection not acquired through perinatal or intravenous
routes
•Clear evidence of penetrating anogenital trauma, without
accidental explanation, namely acute hymenal injury,
laceration/bruising, transaction, absence of tissue especially
in the posterior sector, perianal lacerations or scarring
extending deep to the external sphincter or beyond the anal
margin.
Findings that are highly suspicious but require clarification:

•Evidence of other STIs in the absence of perinatal

acquisition
•Notch/cleft extending through > 50% of the posterior
hymenal rim
•Rapid reflex anal dilatation (RAD) = 1.5-2 cm, without
medical cause, especially if accompanied by irregularity of
the orifice
•Acute abrasions, lacerations of the genitalia
•Bites or suction marks on the genitalia or inner thighs
•Repeated and frequent exhibition of sexualized behavior
 When STI occur in children, sexual abuse must
be considered a “rule out” diagnosis.
•Obtaining a history of abuse from a child with
STI may be difficult,
•but the presence of STI in a child less than 3
years of age is an indication for full exploration of
the possibility of sexual abuse, including
behavioural assessment,
structured interview,
medical examination and
appropriate microbiology.

* The presence of one STI is an indication to

look for others.
CDC recommendation for screening for STI in
sexually abused children. These include:
Females:
•Culture pharynx, anal canal, and vagina for Neisseria
gonorrhoeae
•Culture pharynx, vahina, and rectum for Chlamydia
trachomatis
•Examine urine and culture vagina for Trichomonas
vaginalis
•If inflammation is present, obtain herpes simplex
cultures from vagina, rectum, urethra, or eye area
•Obtain serologic test for syphilis
•Examine for venereal warts
•Examine for vaginitis with a wet mount for clue cells
•Examine for pregnancy if appropriate
Males:

•Culture pharynx, rectum, and urethra for Neisseria

gonorrhoeae
•Culture rectum, pharynx, and urethra for hlamydia
trachomatis
•Obtain herpes simplex culture from areas of the
genital tract which show inflammation
•Obtain serologic test for syphilis
•Examine for venereal warts