A 7-year-old boy is brought to the office due to urinary dribbling for the past 2 months. Symptoms occur during the day as well as overnight. Review of systems is positive for chronic constipation. He has no other chronic medical problems and takes no medications. Temperature is 37.2 C (99 F), blood pressure is 100/60 mm Hg, pulse is 80/min, and respirations are 16/min. Growth parameters are normal. Physical examination shows a tuft of hair above the gluteal cleft and is otherwise normal. Urinalysis is normal. Which is the most appropriate next step in management of this patient?

Question

A 7-year-old boy is brought to the office due to urinary dribbling for the past 2 months.  Symptoms occur during the day as well as overnight.  Review of systems is positive for chronic constipation.  He has no other chronic medical problems and takes no medications.  Temperature is 37.2 C (99 F), blood pressure is 100/60 mm Hg, pulse is 80/min, and respirations are 16/min.  Growth parameters are normal.  Physical examination shows a tuft of hair above the gluteal cleft and is otherwise normal.  Urinalysis is normal.  Which is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d57a_bbeb_bc81_f92e8f261ebd_MD0003_00 This patient with new-onset urinary dribbling has a sacral hair tuft concerning for closed spinal dysraphism (ie, spina bifida occulta), a type of neural tube defect. Presentation and severity can vary greatly; patients may be asymptomatic for years before the insidious onset of symptoms, as seen in this case. Classic manifestations include: Lumbosacral dermatologic findings (eg, dimple, hair tuft, hemangioma, lipoma) Neurologic deficits in the lower extremities, specifically lower motor neuron signs such as weakness, hyporeflexia, and sensory loss Bladder and/or bowel dysfunction due to impaired spinal cord signaling (neurogenic bladder), with symptoms including urinary incontinence, recurrent urinary infections, and chronic constipation Orthopedic complications (eg, foot deformities, scoliosis) are also common and are typically related to underlying weakness. Diagnosis of a suspected spinal dysraphism is with MRI of the spine, which can detect spinal cord tethering and any associated spinal cord lesions (eg, lipoma). Urodynamic studies may also be performed to assess bladder function in these patients. Surgical detethering is the treatment of choice in a symptomatic patient with evidence of tethering on MRI. spinal cord tethering (Choice A) Abdominal ultrasound may be performed in patients with bladder dysfunction to assess for genitourinary tract abnormalities such as vesicoureteral reflux causing hydronephrosis. However, this patient's hair tuft is associated with closed spinal dysraphism and makes a primary genitourinary issue less likely. (Choices B and E) Urinary dribbling can occur in the setting of chronic constipation due to increased bladder pressure from a full, distal colon; evaluation may include abdominal x-ray and laxatives. However, constipation alone does not explain this patient's tuft of hair above the gluteal cleft, so spinal imaging is required. (Choice C) A 24-hour urine volume may be measured for suspected diabetes insipidus, which presents with polyuria due to antidiuretic hormone resistance or deficiency. However, urinalysis would show a low specific gravity, and signs of dehydration are often present on examination. Chronic constipation and a hair tuft are not associated findings. Educational objective: Closed spinal dysraphism (spina bifida occulta) should be suspected in a patient with new-onset urinary incontinence, particularly if lumbosacral cutaneous findings (eg, hair tuft) are present. Diagnosis is with MRI of the spine, and surgical detethering is indicated in symptomatic patients. References: Spinal column shortening for tethered cord syndrome associated with myelomeningocele, lumbosacral lipoma, and lipomyelomeningocele in children and young adults. (http://www.ncbi.nlm.nih.gov/pubmed/28362188)

A 7-Year-Old Boy Is Brought to the Office Due to Urinary