COMMON URINARY TRACT CONCERNS IN CHILDREN Waldo C. Feng M.D.,Ph.D. Childrens Urology Associates Las

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COMMON URINARY TRACT CONCERNS IN CHILDRENWaldo
C. Feng M.D.,Ph.D.Childrens Urology
AssociatesLas Vegas, Nevada
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Urinary Tract Infections in Children

• Presentation - What is this?
• Epidemiology - Who and When?
• Pathogenesis - Why?
• Microbiology - The Culprits
• Management - What We Do and Why

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The Child With UTI

• UTI One of the Most Common Bacterial Infections
• 8 Million Office Visits
• 1.5 Million Hospital Discharges

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UTI Incidence
Kunin, 1998
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PRESENTATION

• Infants and Toddlers
• Non-specific Signs
• Irritability
• Fever
• Failure to Thrive
• Nausea / Vomiting
• Diarrhea
• Hematuria

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PRESENTATION

• School Age Children
• Irritability
• Listlessness
• Pain with Voiding
• Frequency / Urgency
• Foul Odor to Urine
• Unexplained Fever
• New Onset Incontinence
• Abdominal / Flank Pain

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Localization of Infection

• Cystitis Inflammation of the Bladder
• Symptoms / Signs
• Gradual Onset of Fever
• Irritative Voiding Symptoms
• Suprapubic / Urethral Discomfort

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Localization of Infection

• Pyelonephritis Infection of Kidney
• Symptoms / Signs
• Abrupt Onset of Fever
• Shaking Chills
• Flank Pain
• Nausea / Vomiting

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Pathogenesis - UTI

• Ascending Route of UTI
• Bacterial Colonization
• Migration to Periurethral Region
• Migration into Bladder
• Growth in Urine

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Pathogenesis - Pyelonephritis

• Bacterial Ascent to Kidney
• Colonization of Renal Medulla
• Focal Abcess Formation
• Bacteremia
• Kidney Re-infection

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Bacterial Factors

• Virulence Factors
• Cell Wall Antigens
• Serum Resistance
• Hemolytic Capability
• Growth Dynamics
• Iron Scavenging
• Adherence Factors
• P Fimbriae
• Type 1 Fimbriae
• DR Fimbriae

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Host Defense Factors

• Urine pH / Vaginal pH
• Local IgA Antibodies
• Voiding Mechanics

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UTI Risk Factors

• Voiding Dysfunction
• Urinary Tract Abnormalities
• Other Medical Conditions

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UTI Risk Factors

• Foreskin
• Constipation ?
• VUR in Sibling ?

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Common Pathogens

• The Culprits
• Escherichia Coli
• Enterococcus
• P. aeruginosa
• Klebsiella sp.
• Proteus sp.
• Enterobacter sp.
• Coag-negative staph
• Staph aureus
• Candida sp.

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Management of UTI

• Alleviate Acute Morbidity
• Prevent Long-term Sequelae
• Renal Scarring
• Hypertension
• End-Stage Renal Disease

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Renal Scarring - Infection

• First Infection
• 20-35 Children
• 46 Neonates

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Renal Scarring

• 9 1 Episode
• 58 4 Episodes
• May Take 1-2 Years To Develop
• Majority Occur

Bellman, 1995
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UTI Management
Controversy Looms
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Management - UTI

• Diagnosis
• Culture Methods
• Screening Tests
• Anatomic / Functional Evaluation
• Treatment
• Age of Patient
• Severity of Infection
• Prior History of UTI

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Screening Tests

• Microscopic Analysis
• Urine Dipstick Analysis
• Sensitivity 80-90 / Specificity 60-98
• Leukocyte Esterase
• Nitrites
• First Voided Urine Best
• Dietary nitrates

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Culture Methods

• Clean Voided Specimen
• 80 Accuracy
• Bagged Specimen
• Catheterized Specimen
• Suprapubic Aspiration

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Specimen Collection

• Newborns Infants
• Bagged Specimens
• Suprapubic Aspiration
• Urethral Catheterization
• Toddlers
• Bagged Specimens
• Clean Void
• Urethral Catheterization
• School Age Children
• Midstream Clean Catch

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Quantitative Urine Culture

• The Specimen - Midstream Clean Catch Specimen
• 100,000 CFU Significant Colony Count
• Enteric Gram Negative Bacteria

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Anatomic / Functional Evaluation

• Goals
• Assess risk of Damage
• Assess Presence of Damage
• Identify Complicating Factors

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Evauation of UTI

• Physical Exam
• Imaging Studies
• When to Evaluate?
• How To Evaluate?
• RUS
• IVP
• DMSA Scan
• Cystography
• RNC
• VCUG

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UTI Imaging Studies

• Girls
• Initial Studies
• USN
• VCUG
• Follow-up Studies
• USN
• VCUG

• Boys
• Initial Studies
• USN
• VCUG
• Follow-up Studies
• USN
• VCUG

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UTI - Ultrasound

• 2-3 Yield Obstructive Uropathy

Bellman, 1995
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UTI - Voiding Study

• VCUG For 1st Study
• Pyelonephritis Associated With Vesico-Ureteral
  Reflux 50

Bellman, 1995
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Vesico-Ureteral Reflux

• Management
• Medical
• Surgical

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Vesico-Ureteral Reflux

• Surgical Management
• Breakthrough UTI
• Poor Compliance
• Failure of VUR to Resolve

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Medical Management Of VUR

• Suppressive Antibiotic Therapy
• /- Screening Urinalysis
• Treat Voiding Dysfunction
• Serial Imaging Studies

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Voiding Dysfunction

• Appears to Prolong VUR
• Treatment Resolution Rates
• Increases risk of Urinary Tract Infection
• 23 Without UTI
• 65 With UTI

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Voiding Dysfunction

• Urge Incontinence
• Infrequent Voiding
• Lazy Bladder
• Nonneurogenic Neurogenic Bladder

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Voiding Dysfunction - VUR

• 1/3 to 1/2 of Children With UTI VUR
• Not Systematically Reported
• ? Relationship To VUR
• Increases Risk of Breakthrough UTI

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Assessment of Voiding Patterns

• Frequency of Urination
• Frequency / Amount of Incontinence
• Stream Quality
• Time Spent Voiding
• Posturing Maneuvers

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Bladder Retraining Program

• Timed Voiding
• Relaxation Techniques
• Biofeedback Therapy
• Behavior Modification

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Role of Constipation

• Voiding Dysfunction
• Affects 10-40

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Constipation

• Toileting Schedule
• Evaluate Diet
• Healthy Snacks Available
• Mineral Oil / Stool Softeners

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VUR - Sibling Screening

• Incidence in General Population
• 34 In Siblings of Index Patients
• History of UTI
• 25 of Siblings With VUR
• 75 Asymptomatic

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VUR - Sibling Screening

• Rate of Renal Scarring Lower in Siblings
• Higher Rate of VUR Renal Scarring old
• Risk of Renal Scarring At Early Age

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Summary

• UTI in Children - Spectrum of Disease
• Symptoms
• Age
• Multifactorial Etiology
• Diagnosis Management
• Tailor Treatment Accordingly

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Recommendations

• First Febrile UTI
• Presumptive Dx - Pyelonephritis
• ABX Suppression
• Imaging Studies
• USN
• VCUG
• /- DMSA Scan

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Summary

• Evaluation and Treatment Strategies for UTI are
  Dynamic
• Significant Variation in Management Exists

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THE END?