Case 2: An unusual cause of urinary symptoms

Abstract

A 3.5-year-old Mexican-American boy presented to the emergency department with a three-month history of increasing dysuria, voluntary urinary retention and ‘dribbling’. The pain was described as severe, and was localized to the penis and periumbilical area. His mother reported that he had cried on urination since infancy, and although doctors in Mexico had recommended a circumcision, the procedure was never performed. He was otherwise asymptomatic, without fevers or gastrointestinal symptoms. He avoided liquids in an effort to minimize urination, consuming less than 1 L a day. After refusing to urinate for as long as possible, he would exhibit overflow incontinence for several hours. There was no history of prescription or over-the-counter medication use. Past medical history was otherwise unremarkable. Neither his three older siblings nor his parents exhibited similar symptoms at the time. The child’s paternal grandmother had a history of nephrolithiasis resulting in renal failure and nephrectomy. His father had a history of dysuria as a child, for which he was circumcised without further incident. Review of systems was unremarkable. Physical examination revealed an anxious but well-appearing boy. His vital signs were normal, and his height and weight were at the 40th percentile. Abdominal palpation did not elicit pain, and no masses were detected. There was no “flank” tenderness. His rectal tone was normal, as was the neurological examination of the legs. The penis was uncircumcised without any gross abnormalities of the foreskin or urethral meatus. The penis was not tender to palpation, and the foreskin was easily retractable. Initial laboratory studies included a normal complete blood count, albumin, phosphate, blood urea nitrogen and creatinine. The chemistry panel revealed a normal anion gap acidosis with a sodium of 135 mmol/L, potassium of 3.3 mmol/L, chloride of 106 mmol/L and bicarbonate of 17 mmol/L. This acidosis resolved itself over the course of hospitalization with intravenous hydration. Urine was collected by catheterization, and urinalysis revealed 3+ leukocyte esterase, positive nitrites, pH of 6.5, 1+ protein, 3+ blood, 25 to 50 white blood cells/high power field, eight to 25 red blood cells/high power field, no casts and many bacteria. Urine culture grew greater than 100,000 colony forming units/mL of Escherichia coli, Morganella morganii and Enterococcus faecalis. Further investigation elucidated the underlying problem.