1. 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

2. Why is UTI important in children ?

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

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

5. What is the pathogenesis?
Host
Bacteria

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

7. What is the essential history in a child with UTI?

8. 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

9. How to diagnose a UTI? How to collect specimen? Rapid tests?
Confirmation?

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

11. Definitions Simple UTI: low grade fever, dysuria, frequency, urgency
Complicated UTI; fever >38.5, vomiting, dehydration, renal angle tenderness
Recurrent UTI: Second attack of UTI
Relapsing UTI: UTI with same strain
Breakthrough UTI: UTI while on prophylaxis

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

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

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

15. Role & timing of Investigations
USG: helps to detect PC dilatation, ureter dilatation, bladder thickening, ureterocele, post void residual (useful in acute phase when obstruction suspected)
DMSA: ideally after 3m to detect scarring
MCU: provides anatomical information of urethra / ureters; grading of reflux possible
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

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

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

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

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

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

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

22. Asymptomatic Bacteriuria
1% in girls; 0.05% in boys
Good history and examination
USG to exclude abnormalities
Benign condition
Does not lead to scar
Often non virulent strain
Don’t treat: may get UTI with virulent strain

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

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

25. How long to continue prophylaxis?
resolution rate:
Grade I: 80%; II: 60%; III: 40%; IV: 10%; V 0%
The duration to resolution since diagnosis:
Grade I: 2.5 yrs, II: 5 years and Grade III and IV: 8 years
risk factors for new scarring:
younger age, high-grade reflux, and previous scarring
scarring rate with different grades:
Grade I: 10%, II: 17% and III and above 60%.

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

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

28. Scenario
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
A DMSA scan revealed unscarred kidneys with normal function
A repeat MCU confirmed persistent right-sided grade III reflux
On history symptoms of bladder instability
Treat bladder instability; still has symptoms
Urodynamics examination revealed normal compliance with no instability; still gets recurrent UTIs
Extravesical reimplantation

29. Thank You!