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UTI in Children
- 6. Nov 19
- 15. Importance of kidney • Main waste excreter • Maintain ABB • Maintain body fluid • Makes erythropoietin, renin • Biotransforms VD • Excretes some drugs
- 16. Urinary TractUrinary Tract Infection (UTI)Infection (UTI) in Childrenin Children
- 17. At the end of this session you will learnAt the end of this session you will learn • UTI can be aUTI can be a silentsilent killerkiller • More common inMore common in femalesfemales • Dx needs lab. testsDx needs lab. tests • Upper UTI can be fatalUpper UTI can be fatal • An important c/of CKD,An important c/of CKD, HTN,HTN, FTTFTT • May have underlyingMay have underlying cong. anomaliescong. anomalies • FU is very importantFU is very important
- 18. Facts of UTIFacts of UTI •UTI is common in children: Dx in 1% of boys & 3-8% of girlsUTI is common in children: Dx in 1% of boys & 3-8% of girls 2-8% have an attack by 10yoa. 32-8% have an attack by 10yoa. 3rdrd bacterial inf.bacterial inf. •Highest in <1yoa. Boys more if <6moHighest in <1yoa. Boys more if <6mo (2.7%/0.7%)(2.7%/0.7%) then girls ..then girls .. •School children: UTI is x5 in girlsSchool children: UTI is x5 in girls •Febrile UTI is more common in <1y. 7.5% of F. in <3 mo ofFebrile UTI is more common in <1y. 7.5% of F. in <3 mo of age have UTI & 10% have bacteraemia.age have UTI & 10% have bacteraemia. Meningitis seenMeningitis seen in 3-5% of NB with bacteraemic UTIin 3-5% of NB with bacteraemic UTI •30% UTI in <1y have recurrence: 85% within 6mo of 1y30% UTI in <1y have recurrence: 85% within 6mo of 1y •Cystitis mostly occurs in older childrenCystitis mostly occurs in older children •Asymptomatic bacteriuria in children is not a risk
- 19. TerminologiesTerminologies • Urinary tract:Urinary tract: kidneys, ureters, UB, urethrakidneys, ureters, UB, urethra • Pyuria:Pyuria: ≥10 pus cells/mm≥10 pus cells/mm33 in MSSUin MSSU • Bacteriuria:Bacteriuria: urine contains bacteriaurine contains bacteria • NocturiaNocturia:: one or more voiding during sleepone or more voiding during sleep • EnuresisEnuresis:: involuntary voiding (bedwetting)involuntary voiding (bedwetting) • UrgencyUrgency:: unstoppable urge to voidunstoppable urge to void • HesitancyHesitancy:: difficult initiating voidingdifficult initiating voiding • IncontinenceIncontinence:: involuntary leakage:involuntary leakage: Stress ,,Stress ,, :: leakage onleakage on exertion, sneezing or coughing;exertion, sneezing or coughing; Urge ,,:Urge ,,: leakage with urgencyleakage with urgency
- 20. Urinalysis:Urinalysis: macroscopic & microscopicmacroscopic & microscopic • Done for:Done for: UTIs, kidney stones, screening/evaluating kidneyUTIs, kidney stones, screening/evaluating kidney ds., monitoring DM & HTNds., monitoring DM & HTN • Color, appearance:Color, appearance: dehydration, inf., liver ds., muscledehydration, inf., liver ds., muscle damage. Some drugs change colordamage. Some drugs change color Gross hematuria:Gross hematuria: kidney stone or Cakidney stone or Ca Foamy urine: proteinFoamy urine: protein • Glucose, ketone, Hb, leukocyte esteraseGlucose, ketone, Hb, leukocyte esterase (wbc), nitrites (bacteria), bilirubin,(wbc), nitrites (bacteria), bilirubin, urobilinogen (liver ds. orurobilinogen (liver ds. or hemolysis)hemolysis)
- 21. Epidemiology: UTIEpidemiology: UTI • In US:In US: 4 million OPD visits/y (1%). Urosepsis can be fatal.4 million OPD visits/y (1%). Urosepsis can be fatal. Sexually active women have the most UTIsSexually active women have the most UTIs • 40% females have 1 symptomatic UTI in life40% females have 1 symptomatic UTI in life • Elderly: 10% of M & 20% FElderly: 10% of M & 20% F • x10-12 risk of UTI in uncircumcised boys
- 22. Peculiarities of UTIPeculiarities of UTI • May beMay be asymptomaticasymptomatic (silent killer)(silent killer) • UsuallyUsually no Feverno Fever in Lower UTIin Lower UTI • Nonsp. SymptomsNonsp. Symptoms • Fewer physical signsFewer physical signs • Important c/of FTT, persistent V, RAPImportant c/of FTT, persistent V, RAP • Often has cong. anomaliesOften has cong. anomalies • May causeMay cause jaundicejaundice in young infants, &in young infants, & psychosispsychosis inin elderlyelderly • Long tract predisposes to obstructionLong tract predisposes to obstruction
- 23. Defence Against UTIDefence Against UTI • UBUB isis usuallyusually resistant to colonization viaresistant to colonization via – voidingvoiding – mucosal secretionmucosal secretion – low PH, high osmolality, urealow PH, high osmolality, urea – uroepithelial defenses (cytokines, PMNs)uroepithelial defenses (cytokines, PMNs) – Tamm-Horsfall protein: from ascending limb of LoH &Tamm-Horsfall protein: from ascending limb of LoH & DCT with antimicrobial actionDCT with antimicrobial action
- 24. • Cong. anomaliesCong. anomalies of UT, VURof UT, VUR • DM, old age, sedentary life, poor voiding, catheterDM, old age, sedentary life, poor voiding, catheter • Coitus, stone, constipation, encopresis, holding voidingCoitus, stone, constipation, encopresis, holding voiding • Sickle cell trait/d.Sickle cell trait/d. • Immunosuppression:Immunosuppression: • Obs., instrumentation,Obs., instrumentation, catheterizationcatheterization • NNeurogenic UBeurogenic UB • Little water intake, frequent bathLittle water intake, frequent bath • Renal transplantRenal transplant • UB diverticulumUB diverticulum Risk factors:Risk factors: Both sexesBoth sexes
- 25. Additional Risk factors in ..Additional Risk factors in .. femalesfemales – small straight urethra (4cm), near to anus, preg. (4%),small straight urethra (4cm), near to anus, preg. (4%), coitus, diaphragm, spermicide,coitus, diaphragm, spermicide, menopause, RV Fistula,menopause, RV Fistula, back to front wiping of perineum, holding voidingback to front wiping of perineum, holding voiding malesmales – uncircumcised (x10)uncircumcised (x10) – BHP, condom catheter, PUVBHP, condom catheter, PUV
- 26. More UTI in pregnancy (4%)More UTI in pregnancy (4%) dilatation of ureters & renal pelvises (progesterone)dilatation of ureters & renal pelvises (progesterone) increased urinary pH & glycosuriaincreased urinary pH & glycosuria low ureteric tonelow ureteric tone enlarging uterus:enlarging uterus: urinary stasis & VURurinary stasis & VUR immunosuppressionimmunosuppression AAsymptomatic bacteriuria (4-8%). 25% develop APNsymptomatic bacteriuria (4-8%). 25% develop APN Complications:Complications: APN, preterm, unexplained perinatalAPN, preterm, unexplained perinatal death, IUGRdeath, IUGR After anemia, UTI is the 2After anemia, UTI is the 2ndnd commonest medicalcommonest medical complication in preg.complication in preg.
- 27. Obstructive UropathyObstructive Uropathy FFlow is blocked: urine backs up: injures kidneyslow is blocked: urine backs up: injures kidneys • Common:Common: stone in UB, ureter, kidney;stone in UB, ureter, kidney; BHPBHP • Ca.: UB, ureter, colon, cervical, uterus, metastasisCa.: UB, ureter, colon, cervical, uterus, metastasis • Scar inside or outside of uretersScar inside or outside of ureters • Uncommon: PUJO, neurogenic UB, PUVUncommon: PUJO, neurogenic UB, PUV • Rare: idiopathic HDN of preg.Rare: idiopathic HDN of preg. Site:Site: – Ureter: HDNUreter: HDN. It can be ac., or chr. It can be ac., or chr – UB:UB: enlarged & trabeculated, hydroureterenlarged & trabeculated, hydroureter – Urethra:Urethra: megacystis megauretermegacystis megaureter
- 28. Cong. AnomaliesCong. Anomalies – VUR, PUJOVUR, PUJO – aberrant BVaberrant BV – floating kidneysfloating kidneys – horseshoe ,,horseshoe ,, – duplex ,,duplex ,, – renal cysts, double ureterrenal cysts, double ureter – ear anomaly:ear anomaly: more cong. renal anomalies:more cong. renal anomalies: CHARGE, Townes-CHARGE, Townes- Brocks, branchio-oto-renal, Nager, Miller, diabetic embryopathyBrocks, branchio-oto-renal, Nager, Miller, diabetic embryopathy Immunosuppression – steroids – anticancers – malnutrition – Dm – pregnancy
- 29. Vesicoureteral Reflux (VUR)Vesicoureteral Reflux (VUR) • Ureteric valve dysfunctionUreteric valve dysfunction • Causes APN & renal scarringCauses APN & renal scarring
- 30. VUR ..VUR .. • Urine CSUrine CS • Standard treatmentStandard treatment – AntibioticsAntibiotics – SurgerySurgery – Antibiotics + surgeryAntibiotics + surgery • Prophylaxis is an optionProphylaxis is an option
- 31. PUJ obstructionPUJ obstruction Double ureters
- 33. PUV
- 34. VCUG:VCUG: UB is full &UB is full & contrast refluxescontrast refluxes into both uretersinto both ureters VCUG: voiding cystourethrography
- 35. MCUG
- 37. UB diverticula:UB diverticula: pouches in UB: cong./acquired; oftenpouches in UB: cong./acquired; often asymptomatic, may cause UTI, difficulty voiding, hematuria or abdo.asymptomatic, may cause UTI, difficulty voiding, hematuria or abdo. fullness (voiding incompletely)fullness (voiding incompletely)
- 38. Catheter UTICatheter UTI • Bacteriuria inBacteriuria in 15%15% of cath. pts.of cath. pts. • AllAll chr. cath. pts.: bacteriuriachr. cath. pts.: bacteriuria • MO:MO: E. coli,E. coli, Proteus, Klebsiella, Serratia, Pseud., Enterococci,Proteus, Klebsiella, Serratia, Pseud., Enterococci, CandidaCandida • ABR is commonABR is common • Symptoms are often absent or minimalSymptoms are often absent or minimal • Intermittent cathing reduces inf.Intermittent cathing reduces inf.
- 39. UTIs & DMUTIs & DM • DM has higher risk for UTIsDM has higher risk for UTIs – glycosuriaglycosuria: good growth of bacteria: good growth of bacteria – immune sys. does not respond wellimmune sys. does not respond well – neuropathyneuropathy • incomplete voiding: bacterial survival; retrograde inf.incomplete voiding: bacterial survival; retrograde inf.
- 40. Common OrganismsCommon Organisms Mainly G-veMainly G-ve • Commonest:Commonest: E. coliE. coli (80%),(80%), Staph. saprophyticus, P. mirabilisStaph. saprophyticus, P. mirabilis (more in male)(more in male) • Klebsiella, Ps. aeruginosa,Klebsiella, Ps. aeruginosa, Gardnerella vaginalisGardnerella vaginalis G+veG+ve • E. fecalis, GBS, Staph. epidermidisE. fecalis, GBS, Staph. epidermidis CandidaCandida Chlamydia trachomatisChlamydia trachomatis Mostly ascending infectionMostly ascending infection
- 41. PathogenesisPathogenesis • Common: urethra is colonized & then MOCommon: urethra is colonized & then MO ascendsascends UB &UB & adheres & colonizesadheres & colonizes • CytokinesCytokines PMNsPMNs inflam.inflam. • Ascends ureter & kidneyAscends ureter & kidney PNPN • Invasion may be blood borneInvasion may be blood borne • Septicemia may occur (urosepsis)Septicemia may occur (urosepsis)
- 42. UTI: Anatomical ClassificationUTI: Anatomical Classification • Kidney:Kidney: Ac. PNAc. PN Chr. PNChr. PN • Bladder: Cystitis: ac./chr.Bladder: Cystitis: ac./chr. • UrethritisUrethritis • ProstatitisProstatitis • Epididymo-orchitisEpididymo-orchitis
- 43. Clinical ClassificationClinical Classification • Asymptomatic bacteriuriaAsymptomatic bacteriuria:: • Lower UTI:Lower UTI: • Upper UTIUpper UTI • Recurrent UTI:Recurrent UTI: • Complicated UTI:Complicated UTI:
- 44. CF: age-wiseCF: age-wise NeonatesNeonates (Non-specific):(Non-specific): • llethargyethargy • F.,F., or temp. instabilityor temp. instability • irritabilityirritability • jaundicejaundice • FTT, vomiting, poor appetiteFTT, vomiting, poor appetite
- 45. CF in Young ChildrenCF in Young Children • nocturnal enuresisnocturnal enuresis • day time wettingday time wetting • F., or temp. instabilityF., or temp. instability • febrile fitfebrile fit • irritability, lethargyirritability, lethargy • jaundicejaundice • FTT, vomiting • poor appetite • dysuria, frequency • urgency Potential sequelae: renal scarring, CRF, HTN
- 46. Ac. Upper UTI (APN)Ac. Upper UTI (APN) • HGF: chills rigors, AP, ANV, dysuria, frequency, flank/loinHGF: chills rigors, AP, ANV, dysuria, frequency, flank/loin to groin pain.to groin pain. May have LUTSMay have LUTS • Renal angle tendernessRenal angle tenderness • Elderly: often atypical:Elderly: often atypical: psychosispsychosis may occurmay occur • Bacteremia is commonBacteremia is common Chr. PNChr. PN:: may not be due to inf.may not be due to inf. Lower UTILower UTI:: usually ac.usually ac. • Dysuria, frequency, urgencyDysuria, frequency, urgency (LUTS),(LUTS), nocturia. LB painnocturia. LB pain • Urine is turbid, smelly, gross hematuria (30%), suprapubicUrine is turbid, smelly, gross hematuria (30%), suprapubic discomfort +/- tendernessdiscomfort +/- tenderness • F. often absentF. often absent
- 47. DD of APNDD of APN • Appendicitis, ac. CholecystitisAppendicitis, ac. Cholecystitis • UrolithiasisUrolithiasis • Abruptio placenta, PID, ectopic pAbruptio placenta, PID, ectopic p • Ruptured ovarian cystRuptured ovarian cyst Complication of APNComplication of APN • Septicemia, renal damage, perinephric abscessSepticemia, renal damage, perinephric abscess • In preg:In preg: abortion, LBW, pre-term, IUGR,abortion, LBW, pre-term, IUGR, anemia (BManemia (BM suppression, hemolysis), HTN/PE,suppression, hemolysis), HTN/PE, ARDSARDS Rec. of APN in preg.:10-18%Rec. of APN in preg.:10-18%
- 48. ComComplicated UTIplicated UTI Metabolic, functional, pharmacologic, structural defectsMetabolic, functional, pharmacologic, structural defects of UT can cause persistent/rec. UTI or Rx failureof UT can cause persistent/rec. UTI or Rx failure – feverfever – cong. Anomaliescong. Anomalies – BHPBHP – instrumentationinstrumentation – blockages, surgery, indwelling catheterblockages, surgery, indwelling catheter – Neuropathic UBNeuropathic UB – multi-resistant bacteriamulti-resistant bacteria
- 49. Asymptomatic bacteriuriaAsymptomatic bacteriuria (AB)(AB) • Bacteria in urine w/out SS.Bacteria in urine w/out SS. CS shows a uropathogen. Most need no Rx as no harmMost need no Rx as no harm.. 25% clear, 25%25% clear, 25% symptomatic, reinfection is commonsymptomatic, reinfection is common • Causes:Causes: in some healthy people: women more (more inin some healthy people: women more (more in preg.: 40% have kid. inf.). Catheters often will have itpreg.: 40% have kid. inf.). Catheters often will have it • Rx ifRx if:: DM, stones/transplant, preg., elderly, VUR, youngDM, stones/transplant, preg., elderly, VUR, young children. ABT for long-term catheters may bechildren. ABT for long-term catheters may be harder to Rx as yeast inf. may develop. Rx it before aharder to Rx as yeast inf. may develop. Rx it before a UTUT procedure (complications)procedure (complications) • ComplicationsComplications: APN (: APN (Common in females & elderly)Common in females & elderly)
- 50. Sterile PyuriaSterile Pyuria • Microscopy or a urinary dipstick positive for leukocyteMicroscopy or a urinary dipstick positive for leukocyte esterase but CS is negative (absence of bacteria)esterase but CS is negative (absence of bacteria) • SP is a highly prevalent: 13.9% of F & 2.6% of M. It is 23%SP is a highly prevalent: 13.9% of F & 2.6% of M. It is 23% among inpatients (excluding those with UTIamong inpatients (excluding those with UTI • Causes: systemic illness, ABT, diuresis, TB, Chlamydia,Causes: systemic illness, ABT, diuresis, TB, Chlamydia, appendicitis, etc.appendicitis, etc. (see table)(see table)
- 52. • Although colony counts >100k cfu/ml in voided urine haveAlthough colony counts >100k cfu/ml in voided urine have historically been used to DD bacterial UTI fromhistorically been used to DD bacterial UTI from colonization, many U.S. lab currently report counts >1kcolonization, many U.S. lab currently report counts >1k CFU/ml as being diagnostic of bacteriuriaCFU/ml as being diagnostic of bacteriuria • It is important to consider that lower bacterial counts canIt is important to consider that lower bacterial counts can be a/with UTI. A colony count of 100k CFU/ml would DDbe a/with UTI. A colony count of 100k CFU/ml would DD clinically significant from clinically nonsignificant inf & thusclinically significant from clinically nonsignificant inf & thus reduce the number of positive cultures by 38% relative toreduce the number of positive cultures by 38% relative to the number of cultures that would be considered positivethe number of cultures that would be considered positive with the 1000 CFU per milliliter cutoff point. Use of thewith the 1000 CFU per milliliter cutoff point. Use of the higher cutoff point as the “level to treat” could alsohigher cutoff point as the “level to treat” could also decrease the use of antibiotics.decrease the use of antibiotics.66 • In this article, we review causes of SP& describe a clinicalIn this article, we review causes of SP& describe a clinical approach to its evaluation.approach to its evaluation. • inflammatory changes[inflammatory changes[
- 53. • CAUSES OF SPCAUSES OF SP • Sexually Transmitted InfectionsSexually Transmitted Infections • In 2008, it was estimated that 500 million people worldwide were infected with sexually transmitted virusesIn 2008, it was estimated that 500 million people worldwide were infected with sexually transmitted viruses such as herpes simplex virus type 2 (HSV-2)& human papillomavirus (HPV) or had sexually transmittedsuch as herpes simplex virus type 2 (HSV-2)& human papillomavirus (HPV) or had sexually transmitted infections such as gonorrhea, chlamydia, syphilis, mycoplasma,& trichomoniasis.infections such as gonorrhea, chlamydia, syphilis, mycoplasma,& trichomoniasis.77 More than 300,000 U.S.More than 300,000 U.S. cases of infection withcases of infection with Neisseria gonorrhoeaeNeisseria gonorrhoeae are reported to the CDC/yare reported to the CDC/y • In men, the majority of sexually transmitted infections cause symptomatic urethritis & , less commonly,In men, the majority of sexually transmitted infections cause symptomatic urethritis & , less commonly, epididymitis or disseminated gonococcal infection. Many women may be asymptomatic initially,& pelvicepididymitis or disseminated gonococcal infection. Many women may be asymptomatic initially,& pelvic inflammatory disease may develop without symptoms.inflammatory disease may develop without symptoms.88 • Gonorrhea& ChlamydiaGonorrhea& Chlamydia • Historical& current studies indicate that gonorrhea is a cause of SP.Historical& current studies indicate that gonorrhea is a cause of SP.9,109,10 In asymptomatic men, urine testsIn asymptomatic men, urine tests to detect leukocyte esterase have a sensitivity of 66.7% for the diagnosis of gonorrhea& 60.0% for theto detect leukocyte esterase have a sensitivity of 66.7% for the diagnosis of gonorrhea& 60.0% for the diagnosis of chlamydia. Commercially available nucleic acid hybridization tests provide rapid detection ofdiagnosis of chlamydia. Commercially available nucleic acid hybridization tests provide rapid detection of N.N. gonorrhoeaegonorrhoeae&& Chlamydia trachomatisChlamydia trachomatis..1111 • In an Australian study, 1295 symptomatic men with nongonococcal urethritis& pyuria were evaluated forIn an Australian study, 1295 symptomatic men with nongonococcal urethritis& pyuria were evaluated for sexually transmitted diseases.sexually transmitted diseases. C. trachomatisC. trachomatis was detected in 401 men (31%), &was detected in 401 men (31%), & MycoplasmaMycoplasma genitaliumgenitalium was diagnosed in 134 men (10%).was diagnosed in 134 men (10%).1212 A Japanese study involving 51 men showed that the 16SA Japanese study involving 51 men showed that the 16S ribosomal RNA gene ofribosomal RNA gene of Ureaplasma urealyticumUreaplasma urealyticum (quantified by means of a real-time polymerase-chain-(quantified by means of a real-time polymerase-chain- reaction [PCR] assay) was associated with the presence of symptoms of urethritis& higher leukocyte countsreaction [PCR] assay) was associated with the presence of symptoms of urethritis& higher leukocyte counts in first voided urine.in first voided urine.1313 • Genital Herpes& Herpes ZosterGenital Herpes& Herpes Zoster • Genital vesicular eruption, which is characteristic of HSV-2 infection, extrudes wbc into urine. Pyuria may beGenital vesicular eruption, which is characteristic of HSV-2 infection, extrudes wbc into urine. Pyuria may be associated with HSV-2–associated urethritis& cervicitis.associated with HSV-2–associated urethritis& cervicitis.1414 The diagnosis of genital herpes is determined byThe diagnosis of genital herpes is determined by means of HSV PCR, an antigen-detection immunofluorescence test, or an enzyme immunoassay.means of HSV PCR, an antigen-detection immunofluorescence test, or an enzyme immunoassay.1515 • In a 12-year study involving 423 patients with herpes zoster, 17 patients (4%) manifested changes inIn a 12-year study involving 423 patients with herpes zoster, 17 patients (4%) manifested changes in lumbosacral dermatomes& voiding dysfunction. Twelve patients with cystitis-associated symptoms (3% oflumbosacral dermatomes& voiding dysfunction. Twelve patients with cystitis-associated symptoms (3% of
- 54. Clinical, Epidemiologic, & LabClinical, Epidemiologic, & Lab Assessment of SPAssessment of SP
- 56. Natural History of UTINatural History of UTI • Recurrences (15-30%) may occur within 2-3moRecurrences (15-30%) may occur within 2-3mo • ……. usually occur in clusters followed by long remissions. usually occur in clusters followed by long remissions • Uncomplicated UTI does not lead to CRF/CKDUncomplicated UTI does not lead to CRF/CKD • UTI may accelerate progression of underlying renal ds.UTI may accelerate progression of underlying renal ds.
- 57. Dx. InvestigationsDx. Investigations Urine:Urine: MSSUMSSU for ME & CSfor ME & CS Imaging:Imaging: USG, DMSA, DPTAUSG, DMSA, DPTA • IVU, MCUG/VCUGIVU, MCUG/VCUG • Radionuclide cystogram (RNC)Radionuclide cystogram (RNC) DD between DTPA & DMSA Scan • DTPA Scan: evaluating perfusion, cortical function, obs. in kidneys (splitting function) • DMSA: informs cortical morphology (cortical scarring)
- 58. • Both sexes:Both sexes: 2 mo-2 y with first UTI2 mo-2 y with first UTI • In girlsIn girls 3-7y with febrile UTI3-7y with febrile UTI • AAll children withll children with PN, rec. UTIPN, rec. UTI USG: KUBUSG: KUB DPTA, DMSADPTA, DMSA MCUGMCUG CT, MRICT, MRI Imaging:Imaging: wwho to image?ho to image?
- 59. Clean catch urine sampleClean catch urine sample • It prevents contaminationIt prevents contamination • Collected when urine has been in UB for 2-3 hCollected when urine has been in UB for 2-3 h • Can use a special kit to collect: it has a cup with a lid &Can use a special kit to collect: it has a cup with a lid & wipes. Do not touch the inside of cup or lidwipes. Do not touch the inside of cup or lid • Wash hands with soap & warm waterWash hands with soap & warm water
- 60. GIRLS:GIRLS: Wash inter-labia; use sterile wipes. Legs are spread.Wash inter-labia; use sterile wipes. Legs are spread. Use 2 fingers to spread labia. Use 1 wipe to clean insideUse 2 fingers to spread labia. Use 1 wipe to clean inside from front to back; 2from front to back; 2ndnd to clean urethrato clean urethra • Urinate a small amount into toilet, then holdUrinate a small amount into toilet, then hold • Hold container a few in. from urethra& fill at halfHold container a few in. from urethra& fill at half BOYS:BOYS: Clean glans with a sterile wipe after retractingClean glans with a sterile wipe after retracting foreskin. Urinate a little into toilet, & stop; void again …foreskin. Urinate a little into toilet, & stop; void again …
- 61. INFANTSINFANTS • Use special sticky bag; mayUse special sticky bag; may need 2need 2 • Wash the area with soapWash the area with soap and dry; then place the bagand dry; then place the bag • In boys:In boys: put the entire penisput the entire penis in the bagin the bag • In girls:In girls: place the bag over the labiaplace the bag over the labia bagged urine for ME only!bagged urine for ME only!
- 62. Urine CSUrine CS • Proper collection is v. imp. Colony count:Proper collection is v. imp. Colony count: – suprapubic aspirate >1,000 cfu/mlsuprapubic aspirate >1,000 cfu/ml – catheter specimen >10,000 cfu/mlcatheter specimen >10,000 cfu/ml – MSSUMSSU >100,000 cfu/ml>100,000 cfu/ml • Urinalysis: pyuriaUrinalysis: pyuria 10 pus cells/HPF10 pus cells/HPF positive nitrite/leukocyte esterase onpositive nitrite/leukocyte esterase on dipstickdipstick
- 63. False Negative CultureFalse Negative Culture • AntibioticsAntibiotics • AntisepticsAntiseptics • Urethral syndromeUrethral syndrome • TB of UTTB of UT • DiuresisDiuresis
- 65. DD of UTIDD of UTI • Gonorrhea (+/- syphilis)Gonorrhea (+/- syphilis) • EnteroviasisEnteroviasis • Chemical irritationChemical irritation • In females:In females: trichomoniasis, bacterial vulvo-vaginitis,trichomoniasis, bacterial vulvo-vaginitis, ac.ac. urethral syn.urethral syn., candidosis, other STD. Pus/fluid from, candidosis, other STD. Pus/fluid from penis/vagina is common in STDs but not usually in UTIspenis/vagina is common in STDs but not usually in UTIs Ac. urethral syn:Ac. urethral syn: symptoms of UTI without positivesymptoms of UTI without positive culture (a/withculture (a/with C trachomatisC trachomatis). Mainly in females). Mainly in females
- 66. Management: gManagement: goalsoals • Identify the invader, predisposing factorIdentify the invader, predisposing factor • ABTABT • Remove predisposing factors if possibleRemove predisposing factors if possible
- 67. • Dx of UTI:Dx of UTI: pyuria as well as significant CS of a singlepyuria as well as significant CS of a single uropathogenuropathogen • Rec. UTIs:Rec. UTIs: close FU should be done after 7-14 d of ABTclose FU should be done after 7-14 d of ABT • For anatomic anomaliesFor anatomic anomalies: USG: USG • No AB Px in febrile rec. UTI in infants without VURNo AB Px in febrile rec. UTI in infants without VUR • VCUG/MCUGVCUG/MCUG: not routinely done after 1: not routinely done after 1stst UTIUTI – Do if HDN, scarring, high-grade VUR, obs. uropathy,Do if HDN, scarring, high-grade VUR, obs. uropathy, atypical/complex clinical circumstances, rec. febrile UTIatypical/complex clinical circumstances, rec. febrile UTI AAP: Guidelines for UTI in Children
- 68. Antibiotics for UTIAntibiotics for UTI – co-trimoxazole, cepalosporins, amoxicillin, co-amoxiclav,co-trimoxazole, cepalosporins, amoxicillin, co-amoxiclav, amino glycosidesamino glycosides – nitrofurantoin, fluoroquinolone, etc.nitrofurantoin, fluoroquinolone, etc. Management ..Management ..
- 69. Principles of ABT in UTIPrinciples of ABT in UTI • ShorterShorter course for lower UTIcourse for lower UTI • Longer:Longer: uupper & complicated UTI, prostatitis,pper & complicated UTI, prostatitis, EpididymoorchitisEpididymoorchitis • Combination ABTCombination ABT for complicated UTIfor complicated UTI • Parenteral ABParenteral AB in upper & complicated UTIin upper & complicated UTI • Less frequent & low dose in preventionLess frequent & low dose in prevention • Night dose for preventionNight dose for prevention • Long term Px is in: VUR, obstructive uropathyLong term Px is in: VUR, obstructive uropathy
- 70. • Neonates:Neonates: ampicillin + gentamicin I.Vampicillin + gentamicin I.V • APN:APN: 2 ABT, IV & hydration2 ABT, IV & hydration •Duration of Rx:Duration of Rx: – Cystitis – 3- 7dCystitis – 3- 7d – PN –PN – 14d14d •Prophylaxis: cotrim., cephaclor, cefuroxime, nitrofurantoinProphylaxis: cotrim., cephaclor, cefuroxime, nitrofurantoin Risk of renal scarring is greatest in infants; low doseRisk of renal scarring is greatest in infants; low dose prophylactic AB is recommendedprophylactic AB is recommended
- 71. • Infrequent:Infrequent: treat attackstreat attacks • Need to be treated for 2 wNeed to be treated for 2 w • Look forLook for underlyingunderlying cause: treatcause: treat • In females think of sexual activity:In females think of sexual activity: – avoiding spermicidalavoiding spermicidal – complete voiding after intercoursecomplete voiding after intercourse – post coital single dose ABTpost coital single dose ABT ManagementManagement:: Recurrent UTIRecurrent UTI
- 72. Correct Structural AbnormalitiesCorrect Structural Abnormalities
- 73. • Recurrence may be due to:Recurrence may be due to: - renal involvement, immunosuppression- renal involvement, immunosuppression - structural abnormalities- structural abnormalities - chr. bacterial prostatitis- chr. bacterial prostatitis • Obs. should be corrected, If uncorrectable: Rx for 4-Obs. should be corrected, If uncorrectable: Rx for 4- 6 w or as required6 w or as required – FU monthly by CS & annual assessment of RFFU monthly by CS & annual assessment of RF • Long term prophylaxisLong term prophylaxis:: frequent inf., VUR, obs.frequent inf., VUR, obs. uropathyuropathy
- 74. PrognosisPrognosis • Rx of uncomplicated UTI recover completelyRx of uncomplicated UTI recover completely • Recurrences occur in some pts. within 2-3moRecurrences occur in some pts. within 2-3mo • Frequent UTI usually occurs in clusters f/by long remissionsFrequent UTI usually occurs in clusters f/by long remissions • Rec. uncomplicated UTI: no CKDRec. uncomplicated UTI: no CKD • Rec. complicated UTI: may lead to CKDRec. complicated UTI: may lead to CKD • UTI may deteriorate underlying renal diseaseUTI may deteriorate underlying renal disease
- 75. Follow UpFollow Up • Regular monthly urine RE & CS for 1yRegular monthly urine RE & CS for 1y • Advise about voiding & cleanlinessAdvise about voiding & cleanliness • Recurrence:Recurrence: 20% women with UTI will recur; 30% if 2 attacks; 80% if 3 • Recurrence in childrenRecurrence in children – 12% of children U-512% of children U-5 – 18% of infants <6mo18% of infants <6mo
- 76. What is the prognosis ?What is the prognosis ?
- 77. PreventionPrevention • Plenty of liquidsPlenty of liquids, esp. water:, esp. water: dilutes urine; more voidingdilutes urine; more voiding • Wipe fromWipe from front to back:front to back: prevents MOs in anal regionprevents MOs in anal region from spreading to vagina & urethrafrom spreading to vagina & urethra • Void: when you feel the need. Void soonVoid soon after coitus; aafter coitus; also,lso, drink a glass of waterdrink a glass of water • Avoid potentiallyAvoid potentially irritating feminine products:irritating feminine products: sprays,sprays, douches or powders, etc. in the genital areadouches or powders, etc. in the genital area • Circumcision forCircumcision for boysboys • Cranberry juiceCranberry juice
- 79. Prevention ..Prevention .. AntibioticAntibiotic Daily DosageDaily Dosage Methenamine mandelateMethenamine mandelate 75mg/kg bid75mg/kg bid Nalidixic a.Nalidixic a. 30mg/kg bid30mg/kg bid NitrofurantoinNitrofurantoin 1-2mg/kg od1-2mg/kg od SulfisoxazoleSulfisoxazole 10-20mg/kg bid10-20mg/kg bid Co-trimoxazoleCo-trimoxazole 10mg/kg nightly10mg/kg nightly Cephaclor, cefuroximeCephaclor, cefuroxime 50mg/kg bid50mg/kg bid
- 80. UTI ComplicationsUTI Complications Major complications: APN (~ARF, CRF); sepsis (death)Major complications: APN (~ARF, CRF); sepsis (death) More in the young, elderly, immunosuppressedMore in the young, elderly, immunosuppressed Kidney damage or scarringKidney damage or scarring UTI in preg,: IUGR, LBW, preterm, HTN, neonatal sepsisUTI in preg,: IUGR, LBW, preterm, HTN, neonatal sepsis
- 81. MCQMCQ • Kidney disease is a silent killerKidney disease is a silent killer • Acute PN is a medical emergencyAcute PN is a medical emergency • Lower UTI is more symptomatic than upper UTILower UTI is more symptomatic than upper UTI • Proteus commonest MO in male UTIProteus commonest MO in male UTI • Invading MO reaches the UT by ascendingInvading MO reaches the UT by ascending • Circumcision significantly reduces risk of UTICircumcision significantly reduces risk of UTI
- 82. MCQMCQ • The commonest bacteria in UTI is E coli • Proteus is more common in female • DMSA is for scarring • DPTA for splitting • Enteroviasis can mimic UTI
- 83. MCQMCQ • UTI may cause jaundice in infants • UTI is more common in females of all ages • Cranberry juice may be useful for Px UTI • UTI can cause psychosis in the elderly • Pyuria invariably means UTI
- 84. So I learned something,So I learned something, how about you ?how about you ?
- 85. Confused? Ask again & again!Confused? Ask again & again!
- 87. Next lecture:Next lecture: AGN & NSAGN & NS
- 88. THANK YOU VERYTHANK YOU VERY MUCHMUCH
Editor's Notes
- UTI are 1 of the most common bacterial inf in children. Most inf in boys occur in the first 3mo of life but by school age, the rate decreases in boys & increases in girls. Gram-ve MO are those most commonly isolated in uncomplicated UTI with E coli 70-90%
- pyuria is urine containing wbc or pus; 6-10 or more neutrophils/hpf of unspun, voided mid-stream urine. It can be a sign of UTI. Sterile pyuria, is urine which contains pus cells but is sterile on standard culture. It is often c/by STI, like gonorrhea, or viruses which will not grow in bacterial cultures. It is listed as a SE of some medications like paracetamol. Its is also a/with certain d, like Kawasaki d and GU TB. There are many known causes: systemic or infections, structural and physiological reasons, intrinsic kidney pathology, or drugs. It is not an uncommon finding. But, it may be misleading: standard lab CS may not be optimal for atypical MO. Lab may not report significant growth either because it was not a single MO or a uropathogen. CS &lt;100,000 cfu/mL may due to dilute urine was or an organism may be slow-growing. 50% women presenting with SS& 100-10,000 cfu/mL have genuine UB inf. Pyuria increases significance of a low CS count. Cell count PHF is inaccurate& use of a counting chamber or similar gives more accurate results Aetiology: A recently (past 2w) treated UTI or inadequately …. Fastidious MO (grows only in special media under specific conditions): N gonorrhoeae Renal tract TB, Chlamydial urethritis Contamination with antiseptic or vaginal leukocytes Interstitial nephritis: sarcoidosis (lymphocytes not neutrophils), UT stones Renal papillary necrosis: DM, SCD, analgesic nephropathy UT neoplasm (renal& UB Ca), Polycystic kidneys, Interstitial cystitis, Prostatitis. Kawasaki d. Other reported associations: appendicitis& SLE
- A urinalysis is used to detect & manage UTI, kidney d & Dm. Checking appearance, conc. & content of urine. Abnormal urinalysis results may point to a d. UTI can make urine look cloudy. More protein in urine can be a s/kidney d. Red/Pink Urine: Host of causes. Blood is 1 cause. Dipstick & urinalysis should be undertaken to DD. Strenuous exercise causes marcher’s hematuria. Dehydration causes HC urine. Rhubarb Beets Blackberries Red or pink additives cause this. Laxatives with senna, rifampicin, metronidazole, chlorpromazine & thioridazine propofol warfarin lead & Hg may cause this. Some may also cause hematuria
- Tamm-Horsfall protein (THP) is a high MW glycoprotein. Most abundant protein in urine of healthy individuals
- Remarkable changes in UT in preg. Hormonal& structural changes make it easier for bacteria to travel up. Needs prompt Rx. (HTN & preterm) Predisposing factors: Physiological HDN: (progesterone); calyceal & ureteral dilatation from 10wks; 86% on R. by compression of ureters on the pelvic brim by uterus& ovarian vein Changes in the urethra& UB: VUR& stasis: UB capacity increases in preg (progesterone)& causes upward displacement of UB& elongation of urethra. Incomplete voiding predisposes VUR, stasis& facilitates upper UTI. PG & hormones causes muscle relaxation & reduces peristalsis Increase blood vol: increase RBF (50%), GFR (50%) & urinary output Urine becomes alkaline Glucosuria & aminoaciduria provide excellent culture media Catheterization may cause UTI (2-4% with all aseptic precaution) Process of labour also affects UT UTIs& Menopause: estrogen drops. As estrogen provides some Px against UTIs, its reduction during MP may make some women more susceptible to UTIs. UTIs& Hospital Stays: During a hospital stay, many pts cannot get up to go to toilet& require a catheter. Bacteria can enter. This problem is more frequent in people who have long hospital stays or are in long-term care facilities such as nursing homes. UTIs in the Elderly common in both M & F. Although they may have symptoms commonly a/with UTIs, often UTI symptoms in elderly individuals are different. They may show only symptoms of agitation, delirium, confusion & /or behavioral changes. The elderly are at higher risk of developing complications such as kidney infections or sepsis from UTIs. UTIs in Infants Changing a wet & /or soiled diaper is a good way to help prevent UTIs in children. In addition, wiping from front to back in both males& females also reduces the chances of developing UTIs. Like the elderly, infants& young children may develop classic UTI symptoms but are unable to communicate them to anyone. However, signs of UTI in children may include fever, odd-smelling urine, decreased food intake, vomiting, abdominal discomfort,& fussy behavior. Early treatment of UTIs in children helps prevent kidney damage. UTIs in Children About 1% of boys& 3% of girls have UTIs before puberty. Some of these children have structural problems in their urinary tracts that allow retrograde flow to easily occur thus giving bacteria an easy route to the kidneys. A pediatric urologist is usually consulted for evaluation& treatment. Other children may delay urination& some may not relax their muscles enough to completely empty their bladder. These children may be helped by increased fluid intake& encouraging more bathroom trips
- Symptoms: slowly or suddenly,& if one or both kidneys are involved. Mild to severe flank pain. The pain may be felt on one or both sides. Fever NV edema Frequency poor stream Dribbling Not feeling as if the bladder is emptied Need to urinate more often at night Decreased amount of urine Blood in urine Exams& Tests: USG CT IVP VCUG Renal nuclear scan MRI RX: Stents or drains placed in the ureter or in the renal pelvis may provide short-term relief. Nephrostomy tubes. Foley catheter. Short-term relief from the blockage is possible without surgery. However, the cause of the blockage must be removed& the urinary system repaired. Surgery may be needed for long-term relief from the problem. Outlook (Prognosis) If the blockage comes on suddenly, kidney damage is less likely if the problem is detected& repaired promptly. Often, the damage to the kidneys goes away. Long-term damage to the kidneys may occur if the blockage has been present for a long time. If only one kidney is damaged, chronic kidney problems are less likely. You may need dialysis or a kidney transplant if there is damage to both kidneys& they do not function, even after the obstruction is repaired. Possible Complications: OU can cause permanent& severe damage to the kidneys, resulting in kidney failure. If the problem was c/by a blockage in the bladder, the bladder may have long-term damage. This may lead to problems emptying the bladder or leakage of urine
- VUR: Gr. I: into distal U; GII: up to P& C; no dilatation, normal C fornicies. GIII: same as II but mild dilatation of PC. GIV: same as III but U& P are 2+dilated,& C are moderately blunted. GV: gross dilatation& tortuosity of UPC with significant blunting of the majority of C. Less common in African Americans
- PUV. Oblique VCUG: filling defect in urethra with a marked change in urethral caliber at the level of the defect, a finding that indicates obstruction. Although the catheter is in place during voiding, the 2y changes crucial for Dx: trabeculated UB, prominent UB neck, dilated elongated posterior urethra are clear
- Enterococcus is a large genus of lactic a. bacteria; are G+ve cocci that often occur in pairs (diplococci) or short chains, & are difficult to DD from strep. on physical characters alone. 2 spp. are common commensal in gut: E. fecalis (90–95%) & E. faecium (5–10%). Rare clusters of inf occur with other spp.: E. casseliflavus, E. gallinarum, and E. raffinosus. They are facultative anaerobic (capable of cellular respiration in both O2-rich & O2-poor environments). Not spore-forming, they are tolerant of a wide range of env. conditions: extreme temp (10–45°C), pH (4.5–10.0), & high NaCl conc. They typically exhibit gamma-hemolysis on sheep&apos;s blood agar
- G vaginalis is a facultative anaerobe Gram-variable rod; causes with many other bacteria mostly anerobic bacterial vaginosis due to a disruption in the normal flora. The resident Lactobacillus in the vagina are responsible for the acidity. Once they have supplanted the flora, AB with anerobic coverage may have to be given to re-establish the equilibrium. G. vaginalis is not the c/of the bacterial vaginosis, but a signal MO of the altered flora. While typically isolated in genital CS, it may also be detected in other samples from blood, urine, & pharynx. Although it is a major sp. present in bacterial vaginosis, it can also be isolated from women without any SS. It has a G+ve cell wall, but because the CW is so thin it can appear either G+ve/-ve under MC. It is associated microscopically with clue cells, which are epithelial cells covered in bacteria. It makes a pore-forming toxin, vaginolysin, which affects only human cells. Protease & sialidase enzyme activities frequently accompany it Rx: metro- & clindamycin in both oral & vaginal gel/cream forms. CF: may be asymptomatic. Vaginal discharge, irritation, fishy odor. In the &quot;amine whiff test&quot; 10% KOH is added to the discharge, a positive result is indicated if a fishy smell is produced. This& other tests can be used to distinguish between vaginal symptoms related to G. vaginalis from other MO (Trichomonas & Candida albicans) which are similar & may require different Rx. T vaginalis & G vaginalis have similar clinical presentations& can cause a frothy gray or yellow-green vaginal discharge, pruritus, & produce a positive &quot;whiff-test.&quot; The two can be DD using a wet mount slide, where a swab of the vaginal epithelium is diluted& then placed onto a slide for observation under a microscope. Gardnerella reveals a classic &quot;clue cell&quot; under the microscope, showing bacteria adhering to the surface of sq. epithelial cells. Both conditions are treated with metro- or clindamycin Fungal infections are more likely to affect the bladder& kidney& often reach the kidney through the bloodstream. It does sometimes start in the lower urinary tract (urethra& bladder) as a result of the insertion of a catheter when treating other urinary tract conditions. Commonest fungus of a UTI is Candida species although other species (Cryptococcus spp, Aspergillus spp) may be. Fungal UTI like renal candidiasis is rare& mostly seen in immunocompromised (HIV/AIDS, uncontrolled DM, Ca, chemo-) Enterococcus faecalis and Enterococcus faecium: Nonhemolytic streptococci, gamma haemolytic streptococci, enterococcus, group D streptococci, vancomycin-resistant enterococcus (VRE). Formerly known as Streptococcus faecalis and Streptococcus faecium.
- Urosepsis is the ac. systemic inf. In blood that develops 2y to a UTI
- Chr. PN is characterized by renal inflam & fibrosis induced by rec./persistent renal inf, VUR, or other c/of UT obs. Dx is based on US/CT. It occurs almost exclusively in major anatomic anomalies, most commonly in young children with VUR (cong. incompetence of UV valve due to a short intramural segment). VUR is seen in 40% young children with symptomatic UTIs & in almost all children with renal scars. It may also be acquired by pts. with a flaccid UB. Dx of VUR is frequently estbd. on the basis of radiologic evidence obtained during an evaluation for RUTI in young children
- Complicated UTI may involve both lower & upper UT. It significantly increases the rate of Rx failures. Its pathophysiology has 4 aspects: Structural abnormalities like calculi, infected cysts, renal/bladder abscesses, certain forms of PN, SC injury, cath. Metabolic/hormonal, like DM & preg Impaired host responses, like transplant (esp. renal transplants) & AIDS Unusual pathogens, like yeast A growing number of CUTIs are healthcare associated. The most common pathogens include E. coli, enterococci, P aeruginosa, candid, K pneumoniae. PN is almost always the result of bacteria migrating from UB to the renal parenchyma, which is enhanced by VUR. In uncomplicated PN, the bacterial invasion & renal damage are limited to the pyelocalyceal-medullary region; in complicated PN, all regions of the kidney may be affected. If the inf progresses, bacteria may invade the blood
- AB: 100k cfu/ml in 2 successive samples with no symptoms 2-11% in preg x2 in preg with sickle cell trait. x3 with DM Associated with UT abnormality If untreated chances of developing acute cystitis (40%), pyelonephritis (22- 27%)& increased chances of chronic renal failure. Pyelonephritis in pregnancy leads to septicaemia in 10-20% case& ARDS in 2% cases. Other complications are IUGR, preterm labour (two times risk), LBW (50%), hypertension& PE (risk is doubled), anaemia (due to marrow suppression, increased RBC destruction& decreased RBC production), chorioamnionitis& amnionitis. Screening for ASB is recommended for pregnant women at first prenatal visit. Or between 12 to 16 wks of pregnancy. Urine culture is an appropriate screening tool
- What is a nuclear medicine renal scan? Renal scan: can be done with 2 substances: DTPA or MAG3 are similar, but MAG3 gives significantly better images in some pts., particularly v young children & those pts. with poor kidney function. Both are used to look at the blood supply, function & excretion of urine from kidneys. It can find out what % each kidney contributes to the total kidney function. A DTPA Scan may also be undertaken to evaluate: renal tubular function and perfusion (how the body fluids circulate through the kidneys); renovascular HTN (high BP in the arteries of the kidneys); RA stenosis; renal tubular obs. & trauma or damage (blockage or interruption of the ureters); renal transplant perfusion and function. How do I prepare for a renal scan? It is imp., prior to having the scan, that you have plenty of fluid to drink and are well hydrated. If the study is being done to evaluate renal HTN or RA stenosis, some BP medications should be stopped x4-7 d. If you think you may be pregnant or are breast feeding you must inform your doctor or specialist who is referring you for the DTPA Scan and the radiology staff where you are having the DTPA Scan. They will discuss with you any need to stop breast feeding and minimise nonessential contact with your baby for a short time. What happens during a renal scan? On arrival, you will be measured for your height and weight and also given some water to drink prior to the scan to make certain you are well hydrated. For the DTPA Scan, you will be lying down on the scanning bed, with the gamma camera under the bed. It is important to keep still during the test as any movement of the body will blur the images and give poor scan results. The imaging itself does not hurt. A small injection in a vein will be given, usually in the arm. A cannula (thin plastic tube) will be inserted into your vein and will stay in the vein for the duration of the test. Apart from the initial prick this should not cause you any discomfort. Through this cannula the radiopharmaceutical is injected. This can be detected by the gamma camera and will provide clear images of the kidneys. After about 15 minutes of scanning, you may be given a second injection through the same cannula of a diuretic called frusemide (Lasix). This causes the kidneys to make more urine by decreasing the amount of water that the kidneys resorb as part of the filtering process. There is also an increased flow of urine through the ureters which makes any obstruction of the ureters easier to see. As with any drug there is a small chance of an allergic or adverse reaction. Please discuss this with your doctor or with the medical staff performing the examination if you have any queries or concerns. The frusemide will help your kidneys to work harder, so your bladder will fill faster. At the end of the scan you may be asked to go to the toilet and empty your bladder, then return for a further 2 minutes of imaging. The cannula is removed before you leave the department. Are there any after effects of a renal scan? There are no after effects of a DTPA Scan. You will not feel any different. If a dose of a diuretic (frusemide) is given to cause an increased flow of urine, you may feel thirsty and need to drink plenty of fluids for the rest of the day so that your body does not dry out and you become dehydrated. You may also need to visit the toilet more often to empty your bladder. How long does a renal scan take? The test itself will take approximately 30 to 60 minutes. The time varies because the rate at which the kidneys function will differ for each individual. What are the risks of a renal scan? There are no known associated risks involved in the DTPA scan itself. The test involves a small dose of ionising radiation which is relatively small and similar to many other routine medical imaging tests. For more detailed information (see radiation risk of medical imaging for adults and children). If you are pregnant or breast feeding, please inform your doctor before booking the scan. Some of the medications that are used in nuclear medicine studies can pass into the mother’s milk and to the baby. You may be asked to discontinue breast feeding for a short time after the scan and will need to express from both breasts. Please discuss with the nuclear medicine physician or technologist when feeding can resume and if you need to limit contact with your baby for a short time. What are the benefits of a renal scan? This test provides information on the blood supply, function and excretion of urine from the kidneys. A DTPA Scan can help your doctor assess how each of your kidneys is working and find out what percentage each kidney contributes to the total kidney function. It is important for your health that your kidneys are functioning properly. Who does the renal scan? A nuclear medicine technologist will give the injection, perform the scan and process the images. A nuclear medicine specialist will review the images along with your medical history, and provide a written report for your referring doctor. See Nuclear Medicine for more details about these health professionals. Where is a renal scan done? A DTPA scan is done in a nuclear medicine department of a hospital or a private radiology or nuclear medicine practice with nuclear medicine facilities. When can I expect the results of my renal scan? The time it takes your doctor to receive a written report on the test or procedure will vary depending on: the urgency with which the results are required by your doctor; the complexity of the test or procedure; whether more information is needed from your doctor before the test or procedure can be interpreted by the radiologist; whether you have had previous X-rays or other medical imaging that need to be compared with this test or procedure (this is commonly the case if you have a disease or condition that is being assessed as to its progress); how the report is sent to your doctor (i.e. phone, email, fax or mail). Please feel free to ask the private practice, clinic, or hospital when the written report will be provided to your doctor. It is important that you discuss the results with your doctor, either in person or on the telephone, so that they can explain what the results mean for you. Nuclear Medicine DMSA Scan Health professional information What is a DMSA scan? DMSA, or dimercaptosuccinic acid, is a radioactive substance (called a tracer) that is injected into a vein and enters the kidneys. It is detected by gamma cameras and enables a scan to be taken of the inside of the kidneys. See nuclear medicine for more detailed information about the processes used. The scan shows which areas of the kidneys are working normally and which areas have been damaged (usually following kidney infections). How do I prepare for a DMSA scan? There is no preparation for a DMSA Scan. You can eat and drink normally. If you think you may be pregnant or are breast feeding you must inform your doctor or specialist who is referring you for the DMSA Scan and the radiology staff where you are having the DMSA Scan. They will discuss with you any need to stop breast feeding and minimise your contact with your baby for a short time. What happens during a DMSA scan? There are 2 parts to a DMSA scan – an injection of a radiopharmaceutical and then images taken with a gamma camera. You will receive a small injection of a radiopharmaceutical into a vein, usually in your arm. Sometimes, the injection may be followed up immediately by pictures being taken with a gamma camera to show which areas of the kidneys are making urine normally and which areas have been damaged. Other radiopharmaceuticals perform this test better and the main purpose of a nuclear medicine DMSA scan is the delayed images. Two to four hours after having the injection you return to have the scan. During this time you will feel no effect from the injection and can maintain normal activities. The radiopharmaceutical is detected by a gamma camera (that takes images or pictures showing the functioning of the kidneys. These can include one or several still “long exposure” images, and often the creation of a 3D image where the camera moves around your whole body taking pictures from many angles. These pictures are then used to create a 3D image of your kidneys. The reason for the delay between the injection and having pictures taken is to give the radiopharmaceutical a chance to be absorbed into the kidneys. You will not feel any different whilst you are being imaged and there is no noise or lights. The radiopharmaceutical you receive is eliminated from your body through the urine. For that reason, you should drink plenty of fluids and urinate frequently following the injection. How much fluid will depend on each individual but you should be well hydrated, and for an adult this could be 3-4 glasses of water. Your urine will not change colour. However, as it contains the radioactive tracer it is recommended that you wash your hands well after going to the toilet. In the case of babies and youngsters in nappies who are having a DMSA scan, there will be a small amount of radioactivity in the urine and therefore on the child’s nappy. The radiotracer will not affect the baby’s skin, but carers should wash the baby’s bottom as is normal practice and wash their hands thoroughly. Cloth nappies need to be washed thoroughly and disposable nappies put in a plastic bag and sealed before being disposed of. Are there any after effects of a DMSA scan? There are no after effects from a DMSA scan of the kidneys. How long does a DMSA scan take? A DMSA scan of the kidneys involves an injection of the DMSA tracer solution and then imaging 2-4 hours after the injection. You can usually leave the hospital, radiology or nuclear medicine practice between the two parts of the procedure and eat and drink normally during this time. The reason for the delay between the 2 parts is to give the solution a chance to be absorbed by the kidneys. The imaging itself takes about half an hour. You will not feel any different whilst you are being imaged. When small children are having a DMSA scan, it can be difficult giving them the DMSA tracer injection, so various techniques are used such as distracting their attention with DVDs/videos or toys. In some cases local anaesthetic may be used or, more rarely, sedation (see how can I make my child’s examination less stressful?). What are the risks of a DMSA scan? There are no risks involved in the DMSA scan procedure itself. There is a small dose of ionising radiation that is similar to other routine medical imaging tests (see radiation risk of medical imaging for adults and children) What are the benefits of a DMSA scan? A DMSA scan enables the doctor to evaluate the functioning tissue of your kidneys because the radiopharmaceutical does not attach itself to areas of the kidneys that are damaged. Doctors can measure the relative function of each kidney to see if one kidney functions differently to the other, and by performing regular DMSA scans they can monitor any changes to inflammation of the kidneys. Who does the DMSA scan? The DMSA scan of the kidneys is performed by nuclear medicine technologists who are trained to perform this type of test. The technologists provide these images to a nuclear medicine specialist. This specialist will direct the technologist on which images are required to give an accurate diagnosis. The specialist also writes a report and sends it back to the doctor who referred you for the DMSA Scan. See nuclear medicine for more detailed information. Where is a DMSA scan done? Most large public and private hospitals and private radiology and nuclear medicine practices have nuclear medicine facilities where DMSA scans are performed. When can I expect the results of my DMSA scan? The time that it takes your doctor to receive a written report on the test or procedure you have had will vary, depending on: the urgency with which the result is needed; the complexity of the examination; whether more information is needed from your doctor before the examination can be interpreted by the radiologist; whether you have had previous X-rays or other medical imaging that needs to be compared with this new test or procedure (this is commonly the case if you have a disease or condition that is being followed to assess your progress); how the report is conveyed from the practice or hospital to your doctor (i.e. phone, email, fax or mail). Please feel free to ask the private practice, clinic, or hospital where you are having your test or procedure when your doctor is likely to have the written report. It is important that you discuss the results with the doctor who referred you, either in person or on the telephone, so that they can explain what the results mean for you. Further information about DMSA scan: This is a simple test to perform that allows the doctor to assess any damage to the kidneys – usually looking for scarring as a result of urinary reflux (backflow of urine from the bladder to the kidneys ) or damage following trauma or reduced blood supply, e.g. from blocked renal arteries. Regular scans (for example one every year) are often performed to monitor any change in the function of the kidneys or their response to treatments you may be having. DMSA: dimercaptosuccinic a. A DMSA scan uses radioactive chemicals to create special pictures of kidneys. These pictures can help assess how well the kidneys are working. DMSA builds up in kidneys. Pictures of the kidneys are then taken using a special camera
- NITRITES: normally are not found in urine but result when bacteria reduce urinary nitrates to nitrites. Many G-ve & some G+ve MO are capable of this, & a positive dipstick nitrite test indicates that these MO are present in significant numbers (&gt;10k/mL). This test is specific but not highly sensitive. Thus, a +ve result is helpful. The nitrite dipstick reagent is sensitive to air, so containers is closed immediately after removing a strip. After 1w of exposure, 1/3rd of strips give false-positive results, and after 2, 3/4ths. Non-nitrate–reducing MO also may cause false-negative results, & pts. who consume a low-nitrate diet may have false-negative results. LEUKOCYTE ESTERASE: is produced by neutrophils & may signal pyuria a/with UTI. To detect significant pyuria accurately, 30sec-2min should be allowed for the dipstick reagent strip to change color, depending in the brand used. Leukocyte casts indicate inflam to the kidney. MO like Chlamydia & Ureaplasma urealyticum should be considered in pts. with pyuria & negative cultures. Other c/of SP: balanitis, urethritis, TB, UB tumors, viral inf, nephrolithiasis, FB, exercise, GN, & steroid & c.phosphamide
- Honeymoon Cystitis: often occurs after sex. A few women get a UTI frequently after sex (honeymoon or not). Sex can push infecting bacteria into urethra. F with a diaphragm are at a higher risk. Ac. urethral syn:(abacterial cystitis): LUTS (frequency, urgency, dysuria, suprapubic discomfort) but no pathogen or any urological abnormality. Dx is based on history, negative CS, dynamic cystourethroscopy & urodynamic studies. The term is now controversial as no Dx criteria & there is an overlap with other Dx (interstitial cystitis). It affects ¼ adult women particularly young Risks: grand multiparity, delivery without episiotomy & 2 or more abortions. More in F & in white. Presentation: suprapubic discomfort, dysuria, frequency. Do thorough abdominal & gynaecological exam DD: Stress incontinence, Atrophic urethritis& vaginal atrophy in peri- or postmenopausal women, UTI, other c/of SP, Urethritis due to: C trachomatis , Lactobacilli, N gonorrhoeae, Ureoplasma urealyticum, Urethral stenosis& spasm. Other structural abnormalities (diverticula), Allergy/irritation (nylon underwear), Trauma during intercourse, Vaginal infection, Generalised anxiety. Investigations: dipstick, microscopy, CS Urethral swab for chlamydia, chlamydial-antigens in first-pass urine sample. If chlamydia-negative& persistent symptoms, obtain a sample by SP aspiration or urethral catheterisation& culture under special conditions for &apos;fastidious&apos; or slow-growing organisms. Any organisms detected in this way are clinically significant. If no infection, consider cystoscopy to exclude non-infective causes. Further investigations may also include pelvic USG, MRI, IVU& urodynamic. Management: psychological problems should be considered; often irrelevant. Behavioural therapy (including biofeedback, meditation,& hypnosis) has been used with some success. Highly acidic foods, including spicy foods, should be avoided. Exercise& massage programmes can be very helpful. Urethral massage may help by encouraging drainage of mucus from chronically infected periurethral glands. Medication: Rx UTI& chlamydia as indicated. Vaginal oestrogen cream may be curative in atrophic urethritis. Surgery: Urethral dilatation assumes that symptoms are due to urethral spasm or stricture. However, there is very little clinical evidence of effectiveness& it may cause periurethral fibrosis leading to urethral strictures. Urethral dilatation is therefore only now performed if true urethral stenosis is found. Complications: Chronic pain may have a severe psychological impact. Prognosis: usually improve with age but may be lifelong
- Stealth UTI UTIs without symptoms are not unusual; urine tests can show that bacteria are present in the urine& the condition is termed asymptomatic bacteriuria. Usually this condition is not treated, but in some patients it is better to treat them with antibiotics (for example, pregnant women, some children,& kidney transplant patients)
- Treating UTIs Dx & Rx of children 2-24mo of age with UTI & unexplained F. Strategies depend on whether ABT immediately or can be delayed safely until CS & urinalysis. Dx is based on pyuria & 50k CFUs/mL of a single uropathogen in an well collected specimen; urinalysis alone does not confirm Dx. After 7-14d of ABT, close FU is done, with evaluation of the urine in febrile episodes. USG of KUB should be done to detect malformation. Routine VCUG after the first UTI is not recommended; VCUG is indicated if HDN, scarring, or other findings that would suggest either VUR/obstruction, as well as in other atypical or complex clinical circumstances. VCUG also should be performed if there is a recurrence of febrile UTI Although severe kidney infections are often treated in the hospital with IV antibiotics, most UTIs (and many mild-to-moderate kidney infections) are treated with oral antibiotics. However, many clinicians are sending urine samples to identify the infecting organisms& determine their antimicrobial resistance. It is not unusual for a doctor to call a patient& switch antibiotics because of antibiotic resistance. In addition, the doctor will usually recommend that the patient take in plenty of fluids (water)& encourage frequent urination to flush bacteria out of the urinary tract. Treating Recurrent UTIs Recurrent UTIs are not unusual; you should ask your primary care physician (PCP) for a referral to a urologist if you have three or more UTIs per year to see if there may be an underlying urinary tract problem that may be the cause. Your PCP may also suggest taking long-term (months) low-dose antibiotics, recommend taking an oral antibiotic after sex, or taking an oral antibiotic as needed when UTI symptoms appear.
- Cranberry juice: may have infection-fighting properties& drinking it daily may help prevent UTI. Greatest effect in women with rec. UTIs. There&apos;s little harm to drink it, but watch the calories. Mostly safe, but may upset stomach. Don&apos;t drink it if you take the warfarin, because this may lead to bleeding