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Common Ut Concerns In Children

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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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