Common Ut Concerns In Children
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  • Probably one of the most controversial topics among urologist. Who to treat and how to treat.
  • This is the effect of foreskin. Children are beginning to potty-train- dysfunctional voiding.
  • Unlike adults, we have to more perceptive about symptoms. Do not present with dysuria, supra pubic pain. Hematuria on dipstick. Children present diferently at different ages.
  • UTI is a generic term. We try to localize the infection to determine our course of investigation with imaging, and treatment. Bladder infections are low grade temperature, goes down with tynelol.
  • High grade temperature.
  • Other routes hematogenous, lymphatic but the most common is ascending route. Why girls are more at risk than boys,
  • E. Coli most common organism. Over 150 strains, fewer than 10 account for the majority of the cases. It relates to the virulence factor. 91% E.coli causing pyelo have the fimbriae.
  • Breast feeding have some protective effect. Most important easiest to perform is good voiding habits. Do not ask the child when to void, put on a schedule. Fast flowing river clear versus a stagnant pool. Doubling time every 40 minutes.
  • So who are at risk for UTI’s. Reflux, PUV, duplicated ureters. Immunocompromise, neurogenic bladder.
  • Look for some clues in the history and physical.
  • Most common are gram negative enteric bacteria.
  • The goals of treatment is two fold. Certainly early detection, imaging have dramatically reduced the long-term sequelae.
  • Widespread use of DMSA technetium 99 dimercaptosuccinic acid with febrile uti’s up to 50% 2 to 2 years later show scarring. Next slide an example of DMSA.
  • Any photopenic areas are scarred, non functioning nephrons. What are the chances of renal scarring?
  • What to look on a office dipstick since few places do direct microscopic analysis.
  • Bagged is good a ruling out a UTI, not useful in documenting one. SP is the gold standard.
  • Suggest you have an infection.
  • Once we have made a diagnosis of UTI-

Transcript

  • 1. COMMON URINARY TRACT CONCERNS IN CHILDREN Waldo C. Feng M.D.,Ph.D. Children’s Urology Associates Las Vegas, Nevada
  • 2. Urinary Tract Infections in Children
    • Presentation - What is this?
    • Epidemiology - Who and When?
    • Pathogenesis - Why?
    • Microbiology - The Culprits
    • Management - What We Do and Why
  • 3. The Child With UTI
    • UTI One of the Most Common Bacterial Infections
    • 8 Million Office Visits
    • 1.5 Million Hospital Discharges
  • 4. UTI Incidence Kunin, 1998
  • 5. PRESENTATION
    • Infants and Toddlers
    • *Non-specific Signs
      • Irritability
      • Fever
      • Failure to Thrive
      • Nausea / Vomiting
      • Diarrhea
      • Hematuria
  • 6. PRESENTATION
    • School Age Children
    • Irritability
    • Listlessness
    • Pain with Voiding
    • Frequency / Urgency
    • Foul Odor to Urine
    • Unexplained Fever
    • New Onset Incontinence
    • Abdominal / Flank Pain
  • 7. Localization of Infection
    • Cystitis = Inflammation of the Bladder
    • Symptoms / Signs
      • Gradual Onset of Fever
      • Irritative Voiding Symptoms
      • Suprapubic / Urethral Discomfort
  • 8.
    • Pyelonephritis = Infection of Kidney
    • Symptoms / Signs
      • Abrupt Onset of Fever
      • Shaking Chills
      • Flank Pain
      • Nausea / Vomiting
    Localization of Infection
  • 9. Pathogenesis - UTI
    • Ascending Route of UTI
    • Bacterial Colonization
    • Migration to Periurethral Region
    • Migration into Bladder
    • Growth in Urine
  • 10. Pathogenesis - Pyelonephritis
    • Bacterial Ascent to Kidney
    • Colonization of Renal Medulla
    • Focal Abcess Formation
    • Bacteremia
    • Kidney Re-infection
  • 11. Bacterial Factors
    • Virulence Factors
      • Cell Wall Antigens
      • Serum Resistance
      • Hemolytic Capability
      • Growth Dynamics
      • Iron Scavenging
    • Adherence Factors
      • P Fimbriae
      • Type 1 Fimbriae
      • DR Fimbriae
  • 12. Host Defense Factors
    • Urine pH / Vaginal pH
    • Local IgA Antibodies
    • Voiding Mechanics
  • 13. UTI Risk Factors
    • Voiding Dysfunction
    • Urinary Tract Abnormalities
    • Other Medical Conditions
  • 14. UTI Risk Factors
    • Foreskin
    • Constipation ?
    • VUR in Sibling ?
  • 15. Common Pathogens
    • The Culprits
      • Escherichia Coli
      • Enterococcus
      • P. aeruginosa
      • Klebsiella sp.
      • Proteus sp.
      • Enterobacter sp.
      • Coag-negative staph
      • Staph aureus
      • Candida sp.
  • 16. Management of UTI
    • Alleviate Acute Morbidity
    • Prevent Long-term Sequelae
      • Renal Scarring
      • Hypertension
      • End-Stage Renal Disease
  • 17. Renal Scarring - Infection
    • First Infection
    • 20-35% Children
    • 46% Neonates
  • 18. Renal Scarring
    • 9% 1 Episode
    • 58% 4 Episodes
    • May Take 1-2 Years To Develop
    • Majority Occur < 5 Years of Age
    Bellman, 1995
  • 19. UTI Management Controversy Looms
  • 20. Management - UTI
    • Diagnosis
      • Culture Methods
      • Screening Tests
      • Anatomic / Functional Evaluation
    • Treatment
      • Age of Patient
      • Severity of Infection
      • Prior History of UTI
  • 21. Screening Tests
    • Microscopic Analysis
    • Urine Dipstick Analysis
      • Sensitivity 80-90% / Specificity 60-98%
      • Leukocyte Esterase
      • Nitrites
        • First Voided Urine Best
        • Dietary nitrates
  • 22. Culture Methods
    • Clean Voided Specimen
      • 80% Accuracy
    • Bagged Specimen
    • Catheterized Specimen
    • Suprapubic Aspiration
  • 23. Specimen Collection
    • Newborns & Infants
      • Bagged Specimens
      • Suprapubic Aspiration
      • Urethral Catheterization
    • Toddlers
      • Bagged Specimens
      • Clean Void
      • Urethral Catheterization
    • School Age Children
      • Midstream Clean Catch
  • 24. Quantitative Urine Culture
    • The Specimen - *Midstream Clean Catch Specimen
      • <10,000 CFU Probable Contaminant
      • >100,000 CFU Significant Colony Count
    • Enteric Gram Negative Bacteria
  • 25. Anatomic / Functional Evaluation
    • Goals
      • Assess risk of Damage
      • Assess Presence of Damage
      • Identify Complicating Factors
  • 26. Evauation of UTI
    • Physical Exam
    • Imaging Studies
      • When to Evaluate?
      • How To Evaluate?
      • RUS
      • IVP
      • DMSA Scan
      • Cystography
          • RNC
          • VCUG
  • 27. UTI Imaging Studies
    • Girls
    • Initial Studies
      • USN
      • VCUG
    • Follow-up Studies
      • USN
      • VCUG
    • Boys
    • Initial Studies
      • USN
      • VCUG
    • Follow-up Studies
      • USN
      • VCUG
  • 28. UTI - Ultrasound
    • 2-3 % Yield Obstructive Uropathy
    Bellman, 1995
  • 29. UTI - Voiding Study
    • VCUG For 1st Study
    • Pyelonephritis Associated With Vesico-Ureteral Reflux 50%
    Bellman, 1995
  • 30. Vesico-Ureteral Reflux
    • Management
    • Medical
    • Surgical
  • 31. Vesico-Ureteral Reflux
    • Surgical Management
    • Breakthrough UTI
    • Poor Compliance
    • Failure of VUR to Resolve
  • 32. Medical Management Of VUR
    • Suppressive Antibiotic Therapy
    • +/- Screening Urinalysis
    • Treat Voiding Dysfunction
    • Serial Imaging Studies
  • 33. Voiding Dysfunction
    • Appears to Prolong VUR
      • Treatment Resolution Rates
    • Increases risk of Urinary Tract Infection
      • 23% Without UTI
      • 65% With UTI
  • 34. Voiding Dysfunction
    • Urge Incontinence
    • Infrequent Voiding
      • “ Lazy Bladder”
    • Nonneurogenic Neurogenic Bladder
  • 35. Voiding Dysfunction - VUR
    • 1/3 to 1/2 of Children With UTI & VUR
    • Not Systematically Reported
    • ? Relationship To VUR
    • Increases Risk of Breakthrough UTI
  • 36. Assessment of Voiding Patterns
    • Frequency of Urination
    • Frequency / Amount of Incontinence
    • Stream Quality
    • Time Spent Voiding
    • Posturing Maneuvers
  • 37. Bladder Retraining Program
    • Timed Voiding
    • Relaxation Techniques
    • Biofeedback Therapy
    • Behavior Modification
  • 38. Role of Constipation
    • Voiding Dysfunction
    • Affects 10-40%
  • 39. Constipation
    • Toileting Schedule
    • Evaluate Diet
    • Healthy Snacks Available
    • Mineral Oil / Stool Softeners
  • 40. VUR - Sibling Screening
    • Incidence in General Population < 1%
    • 34% In Siblings of Index Patients
    • History of UTI
      • 25% of Siblings With VUR
      • 75% Asymptomatic
  • 41. VUR - Sibling Screening
    • Rate of Renal Scarring Lower in Siblings
    • Higher Rate of VUR & Renal Scarring < 18 months old
    • Risk of Renal Scarring At Early Age
  • 42. Summary
    • UTI in Children - Spectrum of Disease
      • Symptoms
      • Age
    • Multifactorial Etiology
    • Diagnosis & Management
    • Tailor Treatment Accordingly
  • 43. Recommendations
    • First Febrile UTI
    • Presumptive Dx - Pyelonephritis
    • ABX Suppression
    • Imaging Studies
      • USN
      • VCUG
      • +/- DMSA Scan
  • 44. Summary
    • Evaluation and Treatment Strategies for UTI are Dynamic
    • Significant Variation in Management Exists
  • 45. THE END?