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1. Chlamydial urethritis. Suspect when dysuria, pyuria, but no bacteriuria, is present. Treatment with azithromycin, 1 g in a single dose, or doxycycline, 100 mg twice daily for 7 days, is effective. Alternative treatments: erythromycin, 500 mg 4 times daily for 7 days, or ofloxacin, 300 mg twice daily for 7 days. Patient's sexual partner should also be evaluated and treated. Doxycycline should not be used in children younger than 9 years of age. Ofloxacin should be used with caution in those younger than 18. 2. Gonococcal urethritis. With the emergence of penicillin resistance, cefixime, 400 mg in a single dose, or ceftriaxone, 125 mg IM in a single dose, should be given. Alternative treatments: ciprofloxacin, 500 mg, or ofloxacin, 400 mg, in single doses. Because of frequent coexistence of chlamydial urethritis, appropriate antichlamydial treatment should also be given (see preceding paragraph). Patient's sexual partner should also be evaluated and treated. Use ciprofloxacin and ofloxacin with caution in children younger than 18 years.

C. Vaginitis. Therapy is directed at specific cause.

1. Bacterial vaginitis (group A streptococci). Treatment consists of topical antibiotic ointment (mupirocin).

2. Candidal vaginitis. Topical antifungal (miconazole, butocona-zole, or clotrimazole) for 3-7 days. Alternative treatment for older adolescent: 150-mg single oral dose of fluconazole.

3. Bacterial vaginosis or trichomonal vaginitis. Metronidazole, 2 g as a single dose, is effective.

4. Atrophic vaginitis or labial adhesions. Topical Premarin cream is effective. It should be applied daily for 1 week, then 2-3 times per week thereafter.

D. Dermatitis. Management is tailored to the cause.

1. Contact dermatitis. Frequent diaper changes; gentle, thorough cleansing of area; and application of lubricants and barrier pastes is usually all that is needed. Occasionally a short course of low-potency steroids hastens resolution.

2. Candidal dermatitis. Most cases respond well to topical anti-fungal therapy and worsen with steroids.

E. Urethral Strictures and Meatal Stenosis. Treatment involves dilation if mild stenosis; urethroplasty if stenosis is more severe.

F. Urinary Stones. Treatment depends on size and type of stone and ranges from fluid hydration (to help pass the stone) to lithotripsy with or without extracorporeal shock, to surgical removal. In children with urolithiasis, treatment of the underlying metabolic disorder should be addressed.

G. Posterior Urethral Valves. Treatment consists of surgical valve ablation.

VI. Problem Case Diagnosis. The 4-year-old patient had complained of pain with urination for 3 days. Her urine was reportedly of normal color and smell, and she had neither frequency nor urgency. Review of systems was negative for fever or symptoms of upper respiratory infection, but significant for pruritus in the perineum. Physical exam showed a well-appearing girl in no acute distress. There was no back pain and no abdominal tenderness. Significant erythema of the labia minora and vulva was noted. There was no appreciable discharge. Urinalysis was normal. Patient was diagnosed with contact dermatitis and started on lubricant ointment 4 times a day. Her symptoms resolved in 5 days.

VII. Teaching Pearl: Question. Is dysuria the most common presentation in patients with C trachomatis infection?

VIII. Teaching Pearl: Answer. Although dysuria is a more common presenting feature of chlamydial infection in children, up to 50% of patients are asymptomatic. Girls often present with mucopurulent cervical discharge; boys, with urethral discharge.

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