COMMON URINARY TRACT COMMON URINARY TRACT CONCERNS IN CHILDRENCONCERNS IN CHILDREN

Waldo C. Feng M.D.,Ph.D.Waldo C. Feng M.D.,Ph.D.Children’s Urology AssociatesChildren’s Urology Associates

Las Vegas, NevadaLas Vegas, Nevada

Urinary Tract Infections in Urinary Tract Infections in ChildrenChildren

• Presentation - Presentation - What is this?What is this?

• EpidemiologyEpidemiology - Who and When? - Who and When?

• PathogenesisPathogenesis - Why? - Why?

• MicrobiologyMicrobiology - The Culprits - The Culprits

• ManagementManagement - What We Do and Why - What We Do and Why

The Child With UTIThe Child With UTI

• UTI One of the Most Common UTI One of the Most Common Bacterial InfectionsBacterial Infections

• 8 Million Office Visits8 Million Office Visits

• 1.5 Million Hospital Discharges1.5 Million Hospital Discharges

UTI IncidenceUTI Incidence

Kunin, 1998

PRESENTATIONPRESENTATION

• Infants and ToddlersInfants and Toddlers

• *Non-specific Signs*Non-specific Signs– IrritabilityIrritability– FeverFever– Failure to ThriveFailure to Thrive– Nausea / VomitingNausea / Vomiting– DiarrheaDiarrhea– HematuriaHematuria

PRESENTATIONPRESENTATION• School Age ChildrenSchool Age Children

• IrritabilityIrritability• ListlessnessListlessness• Pain with VoidingPain with Voiding• Frequency / UrgencyFrequency / Urgency• Foul Odor to UrineFoul Odor to Urine• Unexplained FeverUnexplained Fever• New Onset IncontinenceNew Onset Incontinence• Abdominal / Flank PainAbdominal / Flank Pain

Localization of InfectionLocalization of Infection• Cystitis = Cystitis =

Inflammation of the Inflammation of the BladderBladder

• Symptoms / SignsSymptoms / Signs– Gradual Onset of FeverGradual Onset of Fever– Irritative Voiding Irritative Voiding

SymptomsSymptoms– Suprapubic / Urethral Suprapubic / Urethral

DiscomfortDiscomfort

• Pyelonephritis = Pyelonephritis = Infection of KidneyInfection of Kidney

• Symptoms / SignsSymptoms / Signs– Abrupt Onset of Abrupt Onset of

FeverFever– Shaking ChillsShaking Chills– Flank PainFlank Pain– Nausea / VomitingNausea / Vomiting

Localization of InfectionLocalization of Infection

Pathogenesis - UTIPathogenesis - UTI

Ascending Route of UTIAscending Route of UTI

° Bacterial ColonizationBacterial Colonization

° Migration to Periurethral RegionMigration to Periurethral Region

° Migration into BladderMigration into Bladder

° Growth in UrineGrowth in Urine

Pathogenesis - PyelonephritisPathogenesis - Pyelonephritis

• Bacterial Ascent to Bacterial Ascent to KidneyKidney

• Colonization of Renal Colonization of Renal MedullaMedulla

• Focal Abcess Focal Abcess FormationFormation

• BacteremiaBacteremia• Kidney Re-infectionKidney Re-infection

Bacterial FactorsBacterial Factors

• Virulence FactorsVirulence Factors– Cell Wall AntigensCell Wall Antigens– Serum ResistanceSerum Resistance– Hemolytic CapabilityHemolytic Capability– Growth DynamicsGrowth Dynamics– Iron ScavengingIron Scavenging

• Adherence FactorsAdherence Factors– P FimbriaeP Fimbriae– Type 1 FimbriaeType 1 Fimbriae– DR FimbriaeDR Fimbriae

Host Defense FactorsHost Defense Factors

• Urine pH / Vaginal pHUrine pH / Vaginal pH

• Local IgA AntibodiesLocal IgA Antibodies

• Voiding MechanicsVoiding Mechanics

UTI Risk FactorsUTI Risk Factors

Voiding Voiding DysfunctionDysfunction

Urinary Tract Urinary Tract AbnormalitiesAbnormalities

Other Medical Other Medical ConditionsConditions

UTI Risk FactorsUTI Risk Factors

• ForeskinForeskin• Constipation ?Constipation ?• VUR in Sibling ?VUR in Sibling ?

Common PathogensCommon Pathogens

• The CulpritsThe Culprits– Escherichia ColiEscherichia Coli– EnterococcusEnterococcus– P. aeruginosaP. aeruginosa– Klebsiella sp.Klebsiella sp.– Proteus sp.Proteus sp.– Enterobacter sp.Enterobacter sp.– Coag-negative staphCoag-negative staph– Staph aureusStaph aureus– Candida sp.Candida sp.

Management of UTIManagement of UTI

• Alleviate Acute MorbidityAlleviate Acute Morbidity

• Prevent Long-term SequelaePrevent Long-term SequelaeRenal ScarringRenal ScarringHypertensionHypertensionEnd-Stage Renal DiseaseEnd-Stage Renal Disease

Renal Scarring - InfectionRenal Scarring - Infection

• First InfectionFirst Infection

• 20-35% Children20-35% Children

• 46% Neonates46% Neonates

Renal ScarringRenal Scarring

• 9% 1 Episode9% 1 Episode

• 58% 4 Episodes58% 4 Episodes

• May Take 1-2 Years May Take 1-2 Years To DevelopTo Develop

• Majority Occur < 5 Majority Occur < 5 Years of AgeYears of Age Bellman, 1995

UTI ManagementUTI Management

Management - UTIManagement - UTI

• DiagnosisDiagnosis– Culture MethodsCulture Methods– Screening TestsScreening Tests– Anatomic / Functional EvaluationAnatomic / Functional Evaluation

• TreatmentTreatment– Age of PatientAge of Patient– Severity of InfectionSeverity of Infection– Prior History of UTIPrior History of UTI

Screening TestsScreening Tests

• Microscopic AnalysisMicroscopic Analysis

• Urine Dipstick AnalysisUrine Dipstick Analysis– Sensitivity 80-90% / Specificity 60-98%Sensitivity 80-90% / Specificity 60-98%– Leukocyte EsteraseLeukocyte Esterase– NitritesNitrites

• First Voided Urine BestFirst Voided Urine Best• Dietary nitratesDietary nitrates

Culture MethodsCulture Methods

• Clean Voided SpecimenClean Voided Specimen– 80% Accuracy80% Accuracy

• Bagged SpecimenBagged Specimen

• Catheterized SpecimenCatheterized Specimen

• Suprapubic AspirationSuprapubic Aspiration

Specimen CollectionSpecimen Collection• Newborns & InfantsNewborns & Infants

– Bagged SpecimensBagged Specimens– Suprapubic AspirationSuprapubic Aspiration– Urethral CatheterizationUrethral Catheterization

• ToddlersToddlers– Bagged SpecimensBagged Specimens– Clean VoidClean Void– Urethral CatheterizationUrethral Catheterization

• School Age ChildrenSchool Age Children– Midstream Clean CatchMidstream Clean Catch

Quantitative Urine CultureQuantitative Urine Culture

• The SpecimenThe Specimen - - *Midstream Clean Catch Specimen*Midstream Clean Catch Specimen

<10,000 CFU Probable Contaminant<10,000 CFU Probable Contaminant >100,000 CFU>100,000 CFU Significant Colony Count Significant Colony Count

• Enteric Gram Negative BacteriaEnteric Gram Negative Bacteria

Anatomic / Functional Anatomic / Functional EvaluationEvaluation

• GoalsGoals– Assess risk of Assess risk of

DamageDamage– Assess Presence Assess Presence

of Damageof Damage– Identify Identify

Complicating Complicating FactorsFactors

Evauation of UTIEvauation of UTI

• Physical ExamPhysical Exam• Imaging StudiesImaging Studies

– When to Evaluate?When to Evaluate?– How To Evaluate?How To Evaluate?– RUSRUS– IVPIVP– DMSA ScanDMSA Scan– CystographyCystography

– RNCRNC

– VCUGVCUG

UTI Imaging StudiesUTI Imaging Studies

GirlsGirls

• Initial StudiesInitial Studies– USNUSN– VCUGVCUG

• Follow-up StudiesFollow-up Studies– USNUSN– VCUGVCUG

BoysBoys

• Initial StudiesInitial Studies– USNUSN– VCUGVCUG

• Follow-up StudiesFollow-up Studies– USNUSN– VCUGVCUG

UTI - UltrasoundUTI - Ultrasound

• 2-3 % Yield2-3 % Yield Obstructive Obstructive UropathyUropathy

Bellman, 1995

UTI - Voiding StudyUTI - Voiding Study

• VCUG For 1st VCUG For 1st StudyStudy

• Pyelonephritis Pyelonephritis Associated With Associated With Vesico-Ureteral Vesico-Ureteral Reflux Reflux 50%50%

Bellman, 1995

Vesico-Ureteral RefluxVesico-Ureteral Reflux

ManagementManagement

• Medical Medical

• SurgicalSurgical

Vesico-Ureteral RefluxVesico-Ureteral Reflux

Surgical Surgical ManagementManagement

• Breakthrough UTIBreakthrough UTI• Poor CompliancePoor Compliance• Failure of VUR to Failure of VUR to

ResolveResolve

Medical Management Of VURMedical Management Of VUR

• SuppressiveSuppressive Antibiotic Therapy Antibiotic Therapy

• +/- Screening Urinalysis+/- Screening Urinalysis

• Treat Treat Voiding DysfunctionVoiding Dysfunction

• Serial Imaging StudiesSerial Imaging Studies

Voiding DysfunctionVoiding Dysfunction

• Appears to Prolong VURAppears to Prolong VUR– Treatment Resolution RatesTreatment Resolution Rates

• Increases risk of Urinary Tract Increases risk of Urinary Tract InfectionInfection– 23% Without UTI23% Without UTI– 65% With UTI65% With UTI

Voiding DysfunctionVoiding Dysfunction

• Urge Urge IncontinenceIncontinence

• Infrequent Infrequent VoidingVoiding ““Lazy Bladder”Lazy Bladder”

• Nonneurogenic Nonneurogenic Neurogenic Neurogenic BladderBladder

Voiding Dysfunction - VURVoiding Dysfunction - VUR

• 1/3 to 1/2 of Children With UTI & VUR1/3 to 1/2 of Children With UTI & VUR

• Not Systematically ReportedNot Systematically Reported

• ? Relationship To VUR? Relationship To VUR

• Increases Risk of Breakthrough UTIIncreases Risk of Breakthrough UTI

Assessment of Voiding Assessment of Voiding PatternsPatterns

• Frequency of UrinationFrequency of Urination• Frequency / Amount of Frequency / Amount of

IncontinenceIncontinence• Stream QualityStream Quality• Time Spent VoidingTime Spent Voiding• Posturing ManeuversPosturing Maneuvers

Bladder Retraining ProgramBladder Retraining Program

• Timed VoidingTimed Voiding

• Relaxation Relaxation TechniquesTechniques

• Biofeedback TherapyBiofeedback Therapy

• Behavior ModificationBehavior Modification

Role of ConstipationRole of Constipation

• Voiding Voiding DysfunctionDysfunction

• Affects 10-40%Affects 10-40%

ConstipationConstipation

• Toileting ScheduleToileting Schedule• Evaluate DietEvaluate Diet• Healthy Snacks Healthy Snacks

AvailableAvailable• Mineral Oil / Stool Mineral Oil / Stool

SoftenersSofteners

VUR - Sibling ScreeningVUR - Sibling Screening

• Incidence in General Population < 1%Incidence in General Population < 1%

• 34% In Siblings of Index Patients34% In Siblings of Index Patients

• History of UTIHistory of UTI– 25% of Siblings With VUR25% of Siblings With VUR– 75% Asymptomatic75% Asymptomatic

VUR - Sibling ScreeningVUR - Sibling Screening

• Rate of Renal Scarring Lower in Rate of Renal Scarring Lower in SiblingsSiblings

• Higher Rate of VUR & Renal Scarring Higher Rate of VUR & Renal Scarring < 18 months old< 18 months old

• Risk of Renal Scarring At Early AgeRisk of Renal Scarring At Early Age

SummarySummary• UTI in Children - UTI in Children -

Spectrum of Spectrum of DiseaseDisease– SymptomsSymptoms

– AgeAge

• Multifactorial EtiologyMultifactorial Etiology

• Diagnosis & Diagnosis & ManagementManagement

• Tailor Treatment Tailor Treatment AccordinglyAccordingly

RecommendationsRecommendations

First Febrile UTIFirst Febrile UTI

• Presumptive Dx - Presumptive Dx - PyelonephritisPyelonephritis

• ABX SuppressionABX Suppression• Imaging StudiesImaging Studies

– USNUSN– VCUGVCUG– +/- DMSA Scan+/- DMSA Scan

SummarySummary

• Evaluation and Evaluation and Treatment Treatment Strategies for UTI Strategies for UTI are Dynamicare Dynamic

• Significant Significant Variation in Variation in Management Management ExistsExists

THE END?THE END?