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!