Reduced feeding or Vomits more than usual. Fever with no other obvious explanation. Sleepy and lethargic Stops gaining weight or unexpected loss. Has jaundice which gets worse when more than a week old. (Unusual smell to urine) (Seems to be in pain at times and when urine is passed)
MSU, CCU, OK – Bag not. Stick test – if positive to nitrites or leucocytes, lab sample + consider Rx. Lab sample as urgent if: ◦ Known urinary tract anomaly ◦ Symptoms suggestive of pyelonephritis ◦ Under 3 years with suggestive symptoms White cap bottle if small sample but to labe quickly.
Treat rapidly if upper tract features Infants nearly always in this category Amoxycillin excellent – if sensitive – toss a coin? Trimethoprim/Augmentin/Cephalexin Follow up and check sensitivities
Initial symptomatology Fever Vomiting Site of any pain/discomfort Diagnostic accuracy – method of urine collection
Previous infections / undiagnosed fevers Recurrent loin pain Possible neurological symptoms Family history – renal anomalies, renal failure, hypertension
Fluid intake – too few drinks or, in some cases, interfering with appetite. Hygiene – bubble baths, washing hair in bath, frequency, wiping, odour. Symptoms suggestive of thread worm infection. School toilets and access
Plotted height and weight with comparison with previous centiles Blood pressure measurement Abdominal examination Genital examination in pre-pubertal children (unless recorded normal elsewhere) Urinalysis
For all under 4 or in referral categories Renal size Dilation of collecting system and ureter Bladder emptying Congenital abnormality Large calculi No – ionising radiation Atraumatic Costs about 1/10 of an isotope scan
Exclude scarring Exclude reflux – which may predispose to future scarring.
Symptoms of cystitis only – i.e. No upper tract symptoms Age >12 months Clear diagnosis Normal ultrasound Single infection Associated factors e.g. Constipation/soiling, manageable in primary care Time to make above assessment with confidence.
Recogntion of infection (infants especially) Prevention of future infection ◦ Bladder habit ◦ Hygiene issues ◦ Diet (incl. fluids) and Constipation Provide leaflet
Any upper tract symptoms – fever >38, loin pain, vomiting, obvious systemic upset. Two or more infections Any abnormality on ultrasound. Diagnostic doubt Associated risk factors which prove difficult to manage – e.g. constipation/soiling. GP preference
Symptoms or ultrasound findings suggest severe obstruction (e.g. Possible urethral valves / gross renal or ureteric dilation on ultrasound – particularly if during infancy and if bilateral)