Urinary Infection in Children Vesico Ureteric Reflux Dr

Urinary Infection in Children & Vesico Ureteric Reflux Dr. Ramesh Babu Srinivasan M. S. , M. Ch. (Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed) Paediatric Urologist Sri Ramachandra Medical Centre, Porur, Chennai, India

Why is UTI important in children ?

Childhood UTI n 30 -50% have underlying problems n Symptoms can be vague & diagnosis can be missed n Failure to treat scarring; hypertension; loss of function & renal failure

What is the Incidence ? n 5% of girls and 2% of boys will have UTI during childhood n Before 3 m: Boys more susceptible n After 3 m: Boys = Girls

What is the pathogenesis? Host Bacteria

What are the symptoms ? n Often non specific in neonates &infants n Suspect in any infant with unexplained fever > 3 days n Any neonate with fever, lethargy, seizures n Children: fever, diarrhea, abdominal pain n Older Children: burning, urgency, frequency, flank pain, wetting, turbid or foul smelling urine.

What is the essential history in a child with UTI?

History - underlying factors Constipation (pain, consistency / frequency) Bladder Instability (frequency, urgency) Dysfunctional voiding (holding, straining, Vincent’s Curtsey Sign) Toileting habits (position, wiping post void) Drinking history: quantity + quality; bladder stimulants (caffeine, black currant) Bathing habits: bubble baths, shampoo bath Family history/social history

How to diagnose a UTI? n How to collect specimen? n Rapid tests? n Confirmation?

Definition n Significant Bacteriuria: presence of a pure growth of > 105 colony forming units of bacteria/ml n Lower counts may be important, in specimens obtained by urinary catheter n Any growth clinically important if obtained by suprapubic aspiration

Definitions n Simple UTI: low grade fever, dysuria, frequency, urgency n Complicated UTI; fever >38. 5, vomiting, dehydration, renal angle tenderness n Recurrent UTI: Second attack of UTI n Relapsing UTI: UTI with same strain n Breakthrough UTI: UTI while on prophylaxis

Initial Management n Send FBC, BU, S Cr, Electrolytes; Urine n Children with complicated UTI, infants < 3 m and those with systemic signs are admitted for IV antibiotics n Adequate hydration is essential during acute phase n USG and repeat urine culture are necessary if there is no improvement < 48 hrs n If there is obstruction it needs to be relieved (catheter in PUV; nephrostomy in pyonephrosis)

Initial Management n Infants > 3 m and those with simple UTI – oral antibiotics: amoxycillin; co trimoxazole or cephalosporin n Usual duration of treatment is 10 -14 days for complicated and 7 -10 days for simple UTI n After this course, start prophylactic antibiotic until further evaluation in all children < 2 yrs

Investigations after First UTI USG (KUB) Abnormal Normal <2 yr MCU, DMSA 2 -5 yr >5 yr DMSA MCU no further test (if scar + or DMSA not available) MCU, DMSA

Role & timing of Investigations n USG: helps to detect PC dilatation, ureter dilatation, bladder thickening, ureterocele, post void residual (useful in acute phase when obstruction suspected) n DMSA: ideally after 3 m to detect scarring n MCU: provides anatomical information of urethra / ureters; grading of reflux possible n Nuclear Cystogram: Less invasive; less radiation; Older cooperative children required; poor anatomical information; grading difficult; not ideal as first investigation; useful for F/U of reflux

Recurrent UTI Children with recurrent UTI irrespective of age require USG, DMSA & MCU

Antibiotic Prophylaxis n Following First UTI in all children < 2 yrs n Following complicated UTI in children > 5 yrs while waiting for imaging n Children with VUR (up to 5 yrs) n Scars on DMSA even if there is no VUR (stop if repeat MCU or RNCU is normal) n Children with frequent febrile UTI (? Even if imaging is normal)

Antibiotic Prophylaxis Age of Pt Duration First UTI Reflux No reflux/ scar + No reflux; no scar Recurrent UTI (no reflux or scar) All up to 5 yrs All 6 m, re evaluate < 2 yrs 6 m, re evaluate > 2 yrs no prophylaxis All six months

Antibiotic Prophylaxis n Ideal: effective, non toxic with few side effects; does not alter natural flora; does not promote resistance n Cephalexin 10 mg/kg nocte (ideal for < 3 m) n Cotrimoxazole 2 mg/kg nocte (avoid <3 m) n Nitrofurantoin 1 mg/kg nocte (avoid in < 3 m, renal impairment, GI upset)

Measures to reduce recurrent UTI n Avoid tight undergarments n Plenty of fluids; avoid bladder irritants n Regular voiding; double voiding n Perineal hygiene; avoid shampoo/ soap n Control constipation n Circumcision in select group

Breakthrough UTI n Resistant flora n Poor compliance n Inadequate dosing n Poor bladder emptying n Host immunity n Address above issues n double prophylaxis

Asymptomatic Bacteriuria n 1% in girls; 0. 05% in boys n Good history and examination n USG to exclude abnormalities n Benign condition n Does not lead to scar n Often non virulent strain n Don’t treat: may get UTI with virulent strain

What are the principles in the management of VUR? n In the absence of UTI, isolated low pressure VUR does not lead to scar formation n Uncomplicated primary reflux resolves spontaneously UTI VUR Scarring

What is the medical management? n Treat acute episode of UTI n Start prophylactic antibiotics n Investigations to exclude anatomical causes of secondary VUR n Treat factors like constipation, dysfunctional voiding and bladder instability n follow-up, parental commitment and patient compliance are essential for success

How long to continue prophylaxis? n resolution rate: n n The duration to resolution since diagnosis: n n Grade I: 2. 5 yrs, II: 5 years and Grade III and IV: 8 years risk factors for new scarring: n n Grade I: 80%; II: 60%; III: 40%; IV: 10%; V 0% younger age, high-grade reflux, and previous scarring rate with different grades: n Grade I: 10%, II: 17% and III and above 60%.

Indications for Surgery n Anatomical factors – duplex, para uret diverticulum n Obstructed refluxing megaureter n Secondary VUR – treat underlying cause n Primary VUR – failure of conservative treatment n Break through infection; worsening function; new scars n Poor follow up; non compliance n High grade (IV or V) reflux; bilateral reflux; multiple scars

Surgical options n Circumcision n STING n n Teflon, macroplastique, deflux, chondrocytes Ureteric reimplantation n Cohen, Leadbetter, Lich Gregoir, laparoscopic n Transureterostomy n Heminephrectomy, common channel reimplant n Nephrectomy

Scenario n A ten-year-old girl, who was initially managed medically for grade III VUR (on MCUG), was referred to the urologist because she developed two episodes of UTI n A DMSA scan revealed unscarred kidneys with normal function n A repeat MCU confirmed persistent right-sided grade III reflux n On history symptoms of bladder instability n Treat bladder instability; still has symptoms n Urodynamics examination revealed normal compliance with no instability; still gets recurrent UTIs n Extravesical reimplantation

Thank You!