Presentation on theme: "Urinary Infection in Children & Vesico Ureteric Reflux"— Presentation transcript:
1 Urinary Infection in Children & Vesico Ureteric Reflux Dr. Ramesh Babu SrinivasanM.S., M.Ch.(Paed Surg), FRCS Glas, FRCS Edin, FRCS (Paed)Paediatric UrologistSri Ramachandra Medical Centre, Porur, Chennai, India
6 What are the symptoms ? Often non specific in neonates &infants Suspect in any infant with unexplained fever > 3 daysAny neonate with fever, lethargy, seizuresChildren: fever, diarrhea, abdominal painOlder 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 bathFamily history/social history
9 How to diagnose a UTI? How to collect specimen? Rapid tests? Confirmation?
10 DefinitionSignificant Bacteriuria: presence of a pure growth of > 105 colony forming units of bacteria/mlLower counts may be important, in specimens obtained by urinary catheterAny 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 tendernessRecurrent UTI: Second attack of UTIRelapsing UTI: UTI with same strainBreakthrough 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 antibioticsAdequate hydration is essential during acute phaseUSG and repeat urine culture are necessary if there is no improvement < 48hrsIf there is obstruction it needs to be relieved(catheter in PUV; nephrostomy in pyonephrosis)
13 Initial ManagementInfants > 3m and those with simple UTI – oral antibiotics: amoxycillin; co trimoxazole or cephalosporinUsual duration of treatment is days for complicated and 7-10 days for simple UTIAfter this course, start prophylactic antibiotic until further evaluation in all children < 2yrs
14 Investigations after First UTI USG (KUB)AbnormalNormal<2yr 2-5 yr >5yrMCU, DMSAMCU, DMSA DMSA no further testMCU(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 scarringMCU: provides anatomical information of urethra / ureters; grading of reflux possibleNuclear 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 UTIChildren with recurrent UTI irrespective of age require USG, DMSA & MCU
17 Antibiotic Prophylaxis Following First UTI in all children < 2yrsFollowing complicated UTI in children > 5 yrs while waiting for imagingChildren 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 DurationFirst UTIReflux All up to 5 yrsNo reflux/ scar All m, re evaluateNo reflux; no scar < 2 yrs m, re evaluate> 2 yrs no prophylaxisRecurrent 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 resistanceCephalexin 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 undergarmentsPlenty of fluids; avoid bladder irritantsRegular voiding; double voidingPerineal hygiene; avoid shampoo/ soapControl constipationCircumcision in select group
22 Asymptomatic Bacteriuria 1% in girls; 0.05% in boysGood history and examinationUSG to exclude abnormalitiesBenign conditionDoes not lead to scarOften non virulent strainDon’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 formationUncomplicated primary reflux resolves spontaneouslyUTIVURScarring
24 What is the medical management? Treat acute episode of UTIStart prophylactic antibioticsInvestigations to exclude anatomical causes of secondary VURTreat factors like constipation, dysfunctional voiding and bladder instabilityfollow-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 yearsrisk factors for new scarring:younger age, high-grade reflux, and previous scarringscarring rate with different grades:Grade I: 10%, II: 17% and III and above 60%.
26 Indications for Surgery Anatomical factors – duplex, para uret diverticulumObstructed refluxing megaureterSecondary VUR – treat underlying causePrimary VUR – failure of conservative treatmentBreak through infection; worsening function; new scarsPoor follow up; non complianceHigh grade (IV or V) reflux; bilateral reflux; multiple scars
28 ScenarioA 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 UTIA DMSA scan revealed unscarred kidneys with normal functionA repeat MCU confirmed persistent right-sided grade III refluxOn history symptoms of bladder instabilityTreat bladder instability; still has symptomsUrodynamics examination revealed normal compliance with no instability; still gets recurrent UTIsExtravesical reimplantation