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Urinary Infection in Urinary Infection in Children & Children &
Vesico Ureteric Vesico Ureteric RefluxReflux
Dr. Ramesh Babu SrinivasanDr. Ramesh Babu SrinivasanM.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed)M.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed)
Paediatric UrologistPaediatric UrologistSri Ramachandra Medical Centre, Porur, Chennai, Sri Ramachandra Medical Centre, Porur, Chennai,
IndiaIndia
Why is UTI Why is UTI important in important in
children ?children ?
Childhood UTIChildhood UTI
30-50% have underlying problems30-50% have underlying problems
Symptoms can be vague & diagnosis can Symptoms can be vague & diagnosis can
be missed be missed
Failure to treat Failure to treat scarring; hypertension; scarring; hypertension;
loss of function & renal failureloss of function & renal failure
What is the Incidence ?What is the Incidence ?
5% of girls and 2% of boys will have 5% of girls and 2% of boys will have
UTI during childhood UTI during childhood
Before 3m: Boys more susceptibleBefore 3m: Boys more susceptible
After 3m: Boys = GirlsAfter 3m: Boys = Girls
What is the What is the pathogenesis?pathogenesis?
HostHostBacteriaBacteria
What are the symptoms ?What are the symptoms ?
Often non specific in neonates &infantsOften non specific in neonates &infants
Suspect in any infant with unexplained fever > 3 daysSuspect in any infant with unexplained fever > 3 days
Any neonate with fever, lethargy, seizuresAny neonate with fever, lethargy, seizures
Children: fever, diarrhea, abdominal painChildren: fever, diarrhea, abdominal pain
Older Children: burning, urgency, frequency, flank Older Children: burning, urgency, frequency, flank
pain, wetting, turbid or foul smelling urine.pain, wetting, turbid or foul smelling urine.
What is the What is the
essential history essential history
in a child with in a child with
UTI? UTI?
History - underlying History - underlying factorsfactors
Constipation (pain, consistency / frequency)Constipation (pain, consistency / frequency)
Bladder Instability (frequency, urgency)Bladder Instability (frequency, urgency)
Dysfunctional voiding Dysfunctional voiding
(holding, straining, Vincent’s Curtsey Sign)(holding, straining, Vincent’s Curtsey Sign)
Toileting habits (position, wiping post void)Toileting habits (position, wiping post void)
Drinking history: quantity + quality; bladder stimulants Drinking history: quantity + quality; bladder stimulants
(caffeine, black currant)(caffeine, black currant)
Bathing habits: bubble baths, shampoo bathBathing habits: bubble baths, shampoo bath
Family history/social historyFamily history/social history
How to diagnose a UTI?How to diagnose a UTI?
How to collect specimen?How to collect specimen?
Rapid tests?Rapid tests?
Confirmation?Confirmation?
DefinitionDefinition
Significant Bacteriuria: presence of a pure Significant Bacteriuria: presence of a pure
growth of > 10growth of > 1055 colony forming units of colony forming units of
bacteria/mlbacteria/ml
Lower counts may be important, in specimens Lower counts may be important, in specimens
obtained by urinary catheterobtained by urinary catheter
Any growth clinically important if obtained by Any growth clinically important if obtained by
suprapubic aspirationsuprapubic aspiration
DefinitionsDefinitions
Simple UTI: low grade fever, dysuria, Simple UTI: low grade fever, dysuria,
frequency, urgencyfrequency, urgency
Complicated UTI; fever >38.5, vomiting, Complicated UTI; fever >38.5, vomiting,
dehydration, renal angle tendernessdehydration, renal angle tenderness
Recurrent UTI: Second attack of UTIRecurrent UTI: Second attack of UTI
Relapsing UTI: UTI with same strainRelapsing UTI: UTI with same strain
Breakthrough UTI: UTI while on prophylaxisBreakthrough UTI: UTI while on prophylaxis
Initial ManagementInitial Management Send FBC, BU, S Cr, Electrolytes; UrineSend FBC, BU, S Cr, Electrolytes; Urine
Children with complicated UTI, infants < 3m and those Children with complicated UTI, infants < 3m and those
with systemic signs are admitted for IV antibiotics with systemic signs are admitted for IV antibiotics
Adequate hydration is essential during acute phaseAdequate hydration is essential during acute phase
USG and repeat urine culture are necessary if there is USG and repeat urine culture are necessary if there is
no improvement < 48hrsno improvement < 48hrs
If there is obstruction it needs to be relievedIf there is obstruction it needs to be relieved
(catheter in PUV; nephrostomy in pyonephrosis)(catheter in PUV; nephrostomy in pyonephrosis)
Initial ManagementInitial Management
Infants > 3m and those with simple UTI – oral Infants > 3m and those with simple UTI – oral
antibiotics: amoxycillin; co trimoxazole or antibiotics: amoxycillin; co trimoxazole or
cephalosporincephalosporin
Usual duration of treatment is 10-14 days for Usual duration of treatment is 10-14 days for
complicated and 7-10 days for simple UTIcomplicated and 7-10 days for simple UTI
After this course, start prophylactic antibiotic After this course, start prophylactic antibiotic
until further evaluation in all children < 2yrsuntil further evaluation in all children < 2yrs
Investigations after First Investigations after First UTIUTI
USG USG (KUB)(KUB)
NormalNormal AbnormalAbnormal
MCU, DMSAMCU, DMSA<2yr<2yr 2-5 yr2-5 yr >5yr>5yr
MCU, DMSAMCU, DMSA DMSA DMSA no further no further testtest
MCU MCU (if scar + or DMSA not available)(if scar + or DMSA not available)
Role & timing of Role & timing of InvestigationsInvestigations
USGUSG: helps to detect PC dilatation, ureter dilatation, : helps to detect PC dilatation, ureter dilatation,
bladder thickening, ureterocele, post void residual (useful bladder thickening, ureterocele, post void residual (useful
in acute phase when obstruction suspected)in acute phase when obstruction suspected)
DMSADMSA: ideally after 3m to detect scarring: ideally after 3m to detect scarring
MCUMCU: provides anatomical information of urethra / : provides anatomical information of urethra /
ureters; grading of reflux possibleureters; grading of reflux possible
Nuclear CystogramNuclear Cystogram: Less invasive; less radiation; Older : Less invasive; less radiation; Older
cooperative children required; poor anatomical cooperative children required; poor anatomical
information; grading difficult; not ideal as first information; grading difficult; not ideal as first
investigation; useful for F/U of refluxinvestigation; useful for F/U of reflux
Recurrent UTIRecurrent UTI
Children with recurrent UTI irrespective of Children with recurrent UTI irrespective of
age require USG, DMSA & MCUage require USG, DMSA & MCU
Antibiotic ProphylaxisAntibiotic Prophylaxis
Following First UTI in all children < 2yrsFollowing First UTI in all children < 2yrs
Following complicated UTI in children > 5 yrs Following complicated UTI in children > 5 yrs
while waiting for imagingwhile waiting for imaging
Children with VUR (up to 5 yrs)Children with VUR (up to 5 yrs)
Scars on DMSA even if there is no VUR (stop if Scars on DMSA even if there is no VUR (stop if
repeat MCU or RNCU is normal)repeat MCU or RNCU is normal)
Children with frequent febrile UTI (? Even if Children with frequent febrile UTI (? Even if
imaging is normal)imaging is normal)
Antibiotic ProphylaxisAntibiotic Prophylaxis
Age of PtAge of Pt DurationDuration
First UTIFirst UTI
RefluxReflux All All up to 5 yrs up to 5 yrs
No reflux/ scar +No reflux/ scar + All All 6m, re evaluate 6m, re evaluate
No reflux; no scarNo reflux; no scar < 2 yrs < 2 yrs 6m, re 6m, re
evaluateevaluate
> 2 yrs> 2 yrs no prophylaxis no prophylaxis
Recurrent UTIRecurrent UTI All All six months six months (no reflux or scar) (no reflux or scar)
Antibiotic ProphylaxisAntibiotic Prophylaxis
Ideal: effective, non toxic with few side effects; Ideal: effective, non toxic with few side effects;
does not alter natural flora; does not promote does not alter natural flora; does not promote
resistanceresistance
Cephalexin 10 mg/kg nocte (ideal for < 3m)Cephalexin 10 mg/kg nocte (ideal for < 3m)
Cotrimoxazole 2 mg/kg nocte (avoid <3m)Cotrimoxazole 2 mg/kg nocte (avoid <3m)
Nitrofurantoin 1 mg/kg nocte (avoid in < 3m, Nitrofurantoin 1 mg/kg nocte (avoid in < 3m,
renal impairment, GI upset)renal impairment, GI upset)
Measures to reduce Measures to reduce recurrent UTIrecurrent UTI
Avoid tight undergarmentsAvoid tight undergarments
Plenty of fluids; avoid bladder irritantsPlenty of fluids; avoid bladder irritants
Regular voiding; double voidingRegular voiding; double voiding
Perineal hygiene; avoid shampoo/ soapPerineal hygiene; avoid shampoo/ soap
Control constipationControl constipation
Circumcision in select groupCircumcision in select group
Breakthrough UTIBreakthrough UTI
Resistant floraResistant flora
Poor compliancePoor compliance
Inadequate dosingInadequate dosing
Poor bladder emptyingPoor bladder emptying
Host immunityHost immunity Address above issuesAddress above issues
double prophylaxisdouble prophylaxis
Asymptomatic Asymptomatic BacteriuriaBacteriuria
1% in girls; 0.05% in boys1% in girls; 0.05% in boys
Good history and examinationGood history and examination
USG to exclude abnormalitiesUSG to exclude abnormalities
Benign conditionBenign condition
Does not lead to scarDoes not lead to scar
Often non virulent strainOften non virulent strain
Don’t treat: may get UTI with Don’t treat: may get UTI with
virulent strainvirulent strain
In the absence of UTI, isolated low pressure In the absence of UTI, isolated low pressure
VUR does not lead to scar formationVUR does not lead to scar formation
Uncomplicated primary reflux resolves Uncomplicated primary reflux resolves
spontaneouslyspontaneously
What are the principles in the What are the principles in the management of VUR?management of VUR?
UTI VUR
Scarring
Treat acute episode of UTITreat acute episode of UTI
Start prophylactic antibioticsStart prophylactic antibiotics
Investigations to exclude anatomical causes Investigations to exclude anatomical causes
of secondary VUR of secondary VUR
Treat factors like constipation, dysfunctional Treat factors like constipation, dysfunctional
voiding and bladder instability voiding and bladder instability
follow-up, parental commitment and patient follow-up, parental commitment and patient
compliancecompliance are essential for success are essential for success
What is the medical What is the medical management?management?
resolution rate: resolution rate:
Grade I: 80%; II: 60%; III: 40%; IV: 10%; V 0% Grade I: 80%; II: 60%; III: 40%; IV: 10%; V 0%
The duration to resolution since diagnosis: The duration to resolution since diagnosis:
Grade I: 2.5 yrs, II: 5 years and Grade III and IV: 8 years Grade I: 2.5 yrs, II: 5 years and Grade III and IV: 8 years
risk factors for new scarring: risk factors for new scarring:
younger age, high-grade reflux, and previous scarring younger age, high-grade reflux, and previous scarring
scarring rate with different grades: scarring rate with different grades:
Grade I: 10%, II: 17% and III and above 60%. Grade I: 10%, II: 17% and III and above 60%.
How long to continue prophylaxis? How long to continue prophylaxis?
Anatomical factors – duplex, para uret diverticulum Anatomical factors – duplex, para uret diverticulum
Obstructed refluxing megaureter Obstructed refluxing megaureter
Secondary VUR – treat underlying causeSecondary VUR – treat underlying cause
Primary VUR – failure of conservative treatmentPrimary VUR – failure of conservative treatment
Break through infection; worsening function; new scarsBreak through infection; worsening function; new scars
Poor follow up; non compliancePoor follow up; non compliance
High grade (IV or V) reflux; bilateral reflux; multiple scarsHigh grade (IV or V) reflux; bilateral reflux; multiple scars
Indications for SurgeryIndications for Surgery
Circumcision Circumcision
STINGSTING
Teflon, macroplastique, deflux, chondrocytesTeflon, macroplastique, deflux, chondrocytes
Ureteric reimplantationUreteric reimplantation
Cohen, Leadbetter, Lich Gregoir, laparoscopicCohen, Leadbetter, Lich Gregoir, laparoscopic
TransureteroureterostomyTransureteroureterostomy
Heminephrectomy, common channel reimplantHeminephrectomy, common channel reimplant
NephrectomyNephrectomy
Surgical optionsSurgical options
A ten-year-old girl, who was initially managed medically for grade III A ten-year-old girl, who was initially managed medically for grade III
VUR (on MCUG), was referred to the urologist because she VUR (on MCUG), was referred to the urologist because she
developed two episodes of UTI developed two episodes of UTI
A DMSA scan revealed unscarred kidneys with normal function A DMSA scan revealed unscarred kidneys with normal function
A repeat MCU confirmed persistent right-sided grade III reflux A repeat MCU confirmed persistent right-sided grade III reflux
On history symptoms of bladder instability On history symptoms of bladder instability
Treat bladder instability; still has symptomsTreat bladder instability; still has symptoms
Urodynamics examination revealed normal compliance with no Urodynamics examination revealed normal compliance with no
instability; still gets recurrent UTIsinstability; still gets recurrent UTIs
Extravesical reimplantationExtravesical reimplantation
Scenario Scenario
Thank You!Thank You!