Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 32  |  Issue : 4  |  Page : 145-147

Idiopathic urethritis in childhood: Presentation of five cases


1 Department of Pediatrics, Rafina Health Care Centre, Rafina, Greece
2 Pediatric Intensive Care Unit, University Hospital of Patras, Patras, Achaia, Greece
3 Department of Urology, Metropolitan General Hospital, Holargos, Attiki, Greece

Date of Submission17-Mar-2021
Date of Decision20-Mar-2021
Date of Acceptance24-Mar-2021
Date of Web Publication13-Aug-2021

Correspondence Address:
Diomidis Kozyrakis
Department of Urology, Metropolitan General Hospital, Mesogeion 264, Holargos, Attica
Greece
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HUAJ.HUAJ_13_21

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  Abstract 


Introduction: Idiopathic urethritis (IU) in childhood is a rare disease with very few cases reported so far. Methods: During the past 3 years, the medical records of young boys diagnosed with and treated for IU in our department were retrieved and analyzed. Herein, their clinical course is presented, and a brief review of the literature is performed. Results: Five young male patients (mean age: 8.2 years) presented to the pediatric office with blood spotting of the underwear or urethral discharge, with or without dysuria. All the patients were treated in an outpatient basis and the corresponding clinical courses after a mean follow-up was 15.8 months were favorable. Conclusions: IU is a rare disease with a generally benign clinical course. Treatment must be tailored to symptomatic relief with avoidance of antibiotics. An aggressive diagnostic workup should be reserved to those with persistent symptoms or frequent recurrences.

Keywords: Blood, children, idiopathic, spot, urethritis


How to cite this article:
Koutsaftiki C, Papatheodoropoulou A, Kozyrakis D. Idiopathic urethritis in childhood: Presentation of five cases. Hellenic Urology 2020;32:145-7

How to cite this URL:
Koutsaftiki C, Papatheodoropoulou A, Kozyrakis D. Idiopathic urethritis in childhood: Presentation of five cases. Hellenic Urology [serial online] 2020 [cited 2021 Sep 24];32:145-7. Available from: http://www.hellenicurologyjournal.com/text.asp?2020/32/4/145/323795




  Introduction Top


Idiopathic urethritis (IU) in childhood is a rare disease considering that very few papers on this topic have been published so far.[1],[2],[3],[4],[5],[6],[7] Anecdotally, several pediatricians and urologists have treated young patients for intermittent urethral discharge or blood spotting of the underwear. Although it is recognized as a benign condition, some uncertainty exists about the diagnostic workup, optimal treatment, and long-term consequences in the urinary tract.[1],[2],[3] Herein, we present our experience after the diagnosis and treatment of 5 children with IU.


  Methods Top


The medical records of the patients diagnosed with IU were retrieved retrospectively, and the clinical course is presented in [Table 1]. The past medical history focused on urinary and bowel symptoms, arthritis, and ophthalmic symptoms. A meticulous physical examination was performed. In case of uncertainty, urologic, and/or ophthalmologic consultation was requested. Urethral smears along with urine samples were collected from all five patients, and the specimens were microscopically examined. The techniques used for the detection of common bacteria, Neisseria gonorrhea, Chlamydia trachomatis, Mycoplasma hominis/genitalium and Ureaplasma urealyticum are presented in [Table 2]. Ultrasonographic (u/s) examination of the urinary tract was routinely performed in all patients. Voiding cystourethrogram, urethroscopy, and urodynamics were considered on an “as needed” basis to patients with refractory symptoms or frequent recurrences. The follow-up data were also re-evaluated. In case of inadequate posttreatment information, a telephone communication was attempted.
Table 1: Patients characteristics

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Table 2: Techniques used to identify bacteria in urethra specimens and urine samples

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  Results Top


During the last 3 years (September 2016 till August 2019), five young male patients (mean age: 8.2, range: 3–14 years) presented to the pediatric office with blood spotting of the underwear or urethral discharge, with or without dysuria. Noteworthy, in three patients, urethritis was associated with chronic constipation and stool impaction. On macroscopic examination, three children had a pale colored, low-viscous, purulent-like urethral discharge. Their prepuce and glans were of normal appearance. Arthritis and conjunctivitis were not confirmed in any of the children. The urinalysis revealed hematuria in two patients, but it was negative for pyuria. Investigation for the presence of bacteria in the urethral and urine specimens was negative.

All the patients were treated in an outpatient basis, and the corresponding clinical courses after a mean follow-up was 15.8 months (range: 7–26) were favorable. The mean duration of symptoms (including time of recurrence) was 21.4 weeks (range: 3–53 weeks). Antibiotics were not prescribed. To those with severe urinary symptoms, instructions for timed voiding and pelvic floor relaxation were provided accompanied by non steroid anti-inflammatory regimens for several days. In cases of constipation, laxatives were administered. At the first follow-up visit (within a month), two patients were symptoms free and at 3-month follow-up visit, all of them were in a good condition.

Two patients recurred at 8 and 12 months, respectively. The investigation and management were similar to that of the first presentation. In both cases, symptoms rapidly improved when a stricter adherence to the treatment instruction was reported. The ultrasonic imaging results were normal, making any association of IU with urinary tract abnormalities unlikely. Thus far, the need for more invasive urinary studies is not justified to any of the patients.


  Discussion Top


IU is a rare disease with fewer than 170 patients presented in the international literature.[1],[2],[3],[4],[5],[6],[7] It is characterized by urethrorrhagia, urethral discharge, and intermittent hematuria with or without dysuria. It affects primarily the male population of ages between 5 and 15 years.[1],[2],[3],[4] The etiology is unknown. Latent bacterial or viral infections or allergic reaction are implicated in the pathogenesis of IU.[4] It has also been associated with urethra metaplasia, hormonal disorders, or abnormal immune response.[1],[5]

When urethritis is diagnosed, bacterial infection (BI) should be excluded.[2],[4],[6] The differential diagnosis also includes the Reiter's syndrome,[4],[8] lithiasis of the urinary tract, and urinary tract neoplasia.[2],[5] Others have associated the disease with dysfunctional elimination syndrome which is a constellation of symptoms originating from both the urinary tract and the bowel.[1]

Antibiotics are not considered effective for the treatment of this condition[1],[2],[5] when compared with other regimens such as laxatives, biofeedback or a-blockers, the antibacterial treatment yielded lower response rates and longer time for complete response. Thus, conservative treatment focused on the intestinal and urinary symptoms may be an adequate and effective management. In addition, a-blockers have been reported to be well tolerant by pediatric patients and may lead to a rapid resolution of symptoms.[1]

Despite the lack of specific therapy, the clinical course seems to be benign. In the majority of patients, the symptoms resolve within 1 year, and the mean duration of symptoms is approximately 10 months.[2] Nevertheless, duration of up to 8 years has been reported.[7] In cases with prolonged symptomatology or frequent recurrences, a more detailed investigation of the urinary tract should be considered and voiding cystourethrogram, urethrocystoscopy and urodynamic studies may be used. Early endoscopy is not generally justified, not only because of the need for general anesthesia, but also because of the risk of postendoscopy urethral trauma and development of urethral strictures.[2],[5],[7] In contrary to previous reports,[3],[4],[6] we believe that the use of early endoscopy plays a minimal role in the diagnosis, in decision making and in prognosis.

Some IU patients (10%–15%) may develop urethral strictures[3],[4],[5] located primarily in the bulbar urethra.[9] The children and their parents should be informed about this complication which, if ensues, can be treated with urethrotomy (1) or, alternatively, with meticulous dilatation of the urethra (2). Therefore, a prolonged monitoring of the lower urinary tract function could be advised.


  Conclusions Top


IU is a rare disease with a generally benign clinical course. Should BI, lithiasis, tumor and Reiter's syndrome have been excluded, the treatment must be tailored to symptomatic relief with avoidance of antibiotics. An aggressive diagnostic workup should be reserved to those with persistent symptoms or frequent recurrences in which the probability of diagnosing a urethral lesion (e.g., metaplasia and stricture) is higher. Administration of a-blockers in children with IU may offer relief of symptoms but should be further investigated for safety and effectiveness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Herz D, Weiser A, Collette T, Reda E, Levitt S, Franco I. Dysfunctional elimination syndrome as an etiology of idiopathic urethritis in childhood. J Urol 2005;173:2132-7.  Back to cited text no. 1
    
2.
Walker BR, Ellison ED, Snow BW, Cartwright PC. The natural history of idiopathic urethrorrhagia in boys. J Urol 2001;166:231-2.  Back to cited text no. 2
    
3.
Dewan PA, Wilson TM. Idiopathic urethritis in the adolescent male. Eur Urol 1996;4:494-7.  Back to cited text no. 3
    
4.
Williams ID, Mikhael RB. Urethritis in male children. Proc Roy Soc Med 1971;64:133-4.  Back to cited text no. 4
    
5.
Docimo SG, Silver RI, Gonzalez R, Muller SC, Jeffs RD. Idiopathic anterior urethritis in prepubertal and pubertal boys: Pathology and clues to etiology. Urology 1998;51:99-102.  Back to cited text no. 5
    
6.
Harrison SC, Whitaker RH. Idiopathic urethritis in male children. Br J Urol 1987;59:258-60.  Back to cited text no. 6
    
7.
Kaplan GW, Brock WA. Idiopathic urethrorrhagia in boys. J Urol 1982;128:1001-3.  Back to cited text no. 7
    
8.
Wu IB, Schwartz RA. Reiter's syndrome: The classic triad and more. J Am Acad Dermatol 2008;59:113-21.  Back to cited text no. 8
    
9.
Husmann D. Use of sympathetic alpha antagonists in the management of pediatric urologic disorders. Curr Opin Urol 2006;16:277-82.  Back to cited text no. 9
    



 
 
    Tables

  [Table 1], [Table 2]



 

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