COMMON URINARY TRACT CONCERNS IN CHILDREN Waldo C. Feng M.D.,Ph.D. Children’s Urology Associates Las Vegas, Nevada
Urinary Tract Infections in Children <ul><li>Presentation -  What is this? </li></ul><ul><li>Epidemiology  - Who and When?...
The Child With UTI <ul><li>UTI One of the Most Common Bacterial Infections </li></ul><ul><li>8 Million Office Visits </li>...
UTI Incidence Kunin, 1998
PRESENTATION <ul><li>Infants and Toddlers </li></ul><ul><li>*Non-specific Signs </li></ul><ul><ul><li>Irritability </li></...
PRESENTATION <ul><li>School Age Children </li></ul><ul><li>Irritability </li></ul><ul><li>Listlessness </li></ul><ul><li>P...
Localization of Infection <ul><li>Cystitis =  Inflammation of the Bladder </li></ul><ul><li>Symptoms / Signs </li></ul><ul...
<ul><li>Pyelonephritis =  Infection of Kidney </li></ul><ul><li>Symptoms / Signs </li></ul><ul><ul><li>Abrupt Onset of Fev...
Pathogenesis - UTI <ul><li>Ascending Route of UTI </li></ul><ul><li>Bacterial Colonization </li></ul><ul><li>Migration to ...
Pathogenesis - Pyelonephritis <ul><li>Bacterial Ascent to Kidney </li></ul><ul><li>Colonization of Renal Medulla </li></ul...
Bacterial Factors <ul><li>Virulence Factors </li></ul><ul><ul><li>Cell Wall Antigens </li></ul></ul><ul><ul><li>Serum Resi...
Host Defense Factors <ul><li>Urine pH / Vaginal pH </li></ul><ul><li>Local IgA Antibodies </li></ul><ul><li>Voiding Mechan...
UTI Risk Factors <ul><li>Voiding Dysfunction </li></ul><ul><li>Urinary Tract Abnormalities </li></ul><ul><li>Other Medical...
UTI Risk Factors <ul><li>Foreskin </li></ul><ul><li>Constipation ? </li></ul><ul><li>VUR in Sibling ? </li></ul>
Common Pathogens <ul><li>The Culprits </li></ul><ul><ul><li>Escherichia Coli </li></ul></ul><ul><ul><li>Enterococcus </li>...
Management of UTI <ul><li>Alleviate Acute Morbidity </li></ul><ul><li>Prevent Long-term Sequelae </li></ul><ul><ul><li>Ren...
Renal Scarring - Infection <ul><li>First Infection </li></ul><ul><li>20-35% Children </li></ul><ul><li>46% Neonates </li><...
Renal Scarring <ul><li>9%  1 Episode </li></ul><ul><li>58%  4 Episodes </li></ul><ul><li>May Take 1-2 Years To Develop </l...
UTI Management Controversy Looms
Management - UTI <ul><li>Diagnosis </li></ul><ul><ul><li>Culture Methods </li></ul></ul><ul><ul><li>Screening Tests </li><...
Screening Tests <ul><li>Microscopic Analysis </li></ul><ul><li>Urine Dipstick Analysis </li></ul><ul><ul><li>Sensitivity 8...
Culture Methods <ul><li>Clean Voided Specimen </li></ul><ul><ul><li>80% Accuracy </li></ul></ul><ul><li>Bagged Specimen </...
Specimen Collection <ul><li>Newborns & Infants </li></ul><ul><ul><li>Bagged Specimens </li></ul></ul><ul><ul><li>Suprapubi...
Quantitative Urine Culture   <ul><li>The Specimen  -  *Midstream Clean Catch Specimen </li></ul><ul><ul><li><10,000 CFU  P...
Anatomic / Functional Evaluation <ul><li>Goals </li></ul><ul><ul><li>Assess risk of Damage </li></ul></ul><ul><ul><li>Asse...
Evauation of UTI <ul><li>Physical Exam </li></ul><ul><li>Imaging Studies </li></ul><ul><ul><li>When to Evaluate? </li></ul...
UTI Imaging Studies <ul><li>Girls </li></ul><ul><li>Initial Studies </li></ul><ul><ul><li>USN </li></ul></ul><ul><ul><li>V...
UTI - Ultrasound <ul><li>2-3 % Yield   Obstructive Uropathy </li></ul>Bellman, 1995
UTI - Voiding Study <ul><li>VCUG For 1st Study </li></ul><ul><li>Pyelonephritis Associated With Vesico-Ureteral Reflux  50...
Vesico-Ureteral Reflux <ul><li>Management </li></ul><ul><li>Medical  </li></ul><ul><li>Surgical </li></ul>
Vesico-Ureteral Reflux <ul><li>Surgical Management </li></ul><ul><li>Breakthrough UTI </li></ul><ul><li>Poor Compliance </...
Medical Management Of VUR <ul><li>Suppressive  Antibiotic Therapy </li></ul><ul><li>+/- Screening Urinalysis </li></ul><ul...
Voiding Dysfunction <ul><li>Appears to Prolong VUR </li></ul><ul><ul><li>Treatment  Resolution Rates </li></ul></ul><ul><l...
Voiding Dysfunction <ul><li>Urge Incontinence </li></ul><ul><li>Infrequent Voiding </li></ul><ul><ul><li>“ Lazy Bladder” <...
Voiding Dysfunction - VUR   <ul><li>1/3 to 1/2 of Children With UTI & VUR </li></ul><ul><li>Not Systematically Reported </...
Assessment of Voiding Patterns <ul><li>Frequency of Urination </li></ul><ul><li>Frequency / Amount of Incontinence </li></...
Bladder Retraining Program <ul><li>Timed Voiding </li></ul><ul><li>Relaxation Techniques </li></ul><ul><li>Biofeedback The...
Role of Constipation <ul><li>Voiding Dysfunction </li></ul><ul><li>Affects 10-40% </li></ul>
Constipation <ul><li>Toileting Schedule </li></ul><ul><li>Evaluate Diet </li></ul><ul><li>Healthy Snacks Available </li></...
VUR - Sibling Screening <ul><li>Incidence in General Population < 1% </li></ul><ul><li>34% In Siblings of Index Patients <...
VUR - Sibling Screening   <ul><li>Rate of Renal Scarring Lower in Siblings </li></ul><ul><li>Higher Rate of VUR & Renal Sc...
Summary <ul><li>UTI in Children - Spectrum of Disease </li></ul><ul><ul><li>Symptoms </li></ul></ul><ul><ul><li>Age </li><...
Recommendations <ul><li>First Febrile UTI </li></ul><ul><li>Presumptive Dx - Pyelonephritis </li></ul><ul><li>ABX Suppress...
Summary <ul><li>Evaluation and Treatment Strategies for UTI are Dynamic </li></ul><ul><li>Significant Variation in Managem...
THE END?
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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-
  • Common Ut Concerns In Children

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