1. Dr MJ Engelbrecht Dept Urology University of Pretoria
Urinary tract infections and congenital urological abnormalities in children
Dr MJ Engelbrecht
Dept Urology
University of Pretoria

2. Urinary tract infection in children
More common in girls
Boys more common under 1 year
Preputial aerobic bacterial colonization is the highest under 1 year
Uncircumcised infants have a increased risk of UTI vs circumcised boys

3. UTI in Children Diagnosis Interpretation Urine bag
Suprapubic aspiration
Midstream urine specimen
Interpretation
Culture
Midstream or urine bag collected specimen
Single organism > organisms/ml
Any number of organism is significant

4. UTI in children Which UTI should be investigated Investigations
ALL FIRST INFECTIONS MUST BE INVESTIGATED
Investigations
Under 2 years
U/S KUB
VCUG
Over 2 years
VCUG only if
Abnormal ultrasound
Temperature more than 38 degrees

5. UTI in children Abnormalities found (50% of children) VUR Obstruction
85% of urinary tract abnormalities
Obstruction
Posterior urethral valves
PUJ Obstruction
Primary obstructive megaureter
Ureterocele
Other
Neurogenic bladder
Calculi

6. Vesico urethral reflux
Flow of urine from the bladder into the ureters
Normal anti reflux mechanism
Pressure of urine in the bladder on the submucosal ureter.
Therefore normal submucosal length is important.

7. Classification Primary reflux Secondary reflux Short submucosal tunnel
N - Neurogenic bladder
O - Obstruction
T - Trauma or surgery
I - Infection
C - Congenital ureteric abnormalities
E - Ectopic ureteric openings

8. Prevalence 1-2 % of children 20 – 30 % of children with UTI
Outosomal dominant genetic disorder
30% in siblings
50% in offsprings

9. Complications Reflux nephropathy Hypertension Chronic renal failure
20% of pediatric renal transplant patients have reflux nephropathy

10. Diagnosis VCUG Indirect nuclear cystography Ultrasound “gold” standard
Done after the UTI has been treated
Advantages
Grades reflux
Excludes secondary
causes of reflux
Indirect nuclear
cystography
Ultrasound

11. Diagnosis
VCUG

12. Treatment Medical Natural history is spontaneous resolution
50% by 4 to 5 years
80% by puberty
Therefore most patients are treated medically
Treatment only to prevent renal scarring from infections
Includes long term antibiotic prophylaxis and regular follow up (6 monthly ultrasound)
Yearly assessment of the state of reflux with VCUG

13. Treatment Surgical Indications Endoscopic treatment Open surgery
Failure of medical treatment to prevent UTI’s
Non compliance with medical treatment
Severe reflux that is unlikely to resolve
Associated pathology (Uretercele/Diverticulum)
Persistent VUR in adolescent females (prevent problems during pregnancy)
Endoscopic treatment
STING (Subureteric injection of Teflon or Macrplastique)
Open surgery
Reimplantation of ureter into the bladder (>90% success)

14. PUJ Obstruction
Obstruction of the ureter at the pelvic ureteric junction
Primary
Congenital intrinsic obstruction of the ureter
Exstrinsic compression by a abnormal blood vessel
Secondary
In the lumen - Stone or blood clot
In the wall - Stricture from infection or trauma

15. Complications Pyelonehritis Loss of normal renal function
Renal failure if bilateral
Calculi due to stasis
The kidney is more prone to trauma
Hypertension
Pain due to obstruction

16. Diagnosis Ultasound IVP MAG 3 renogram First investigation
Will show hydronehrosis with normal ureter
IVP
Show dilated renal pelvis with normal ureter
MAG 3 renogram

17. Diagnosis

18. Treatment Conservative Surgical
If no complications and > 40% differential function
Regular follow up with renal ultrasound
Surgical
Indications
Decrease in differential function
Complications
UTI
Renal failure
Calculi

19. Treatment Surgical Open surgical Endoscopic Laparoscopic Nephrectomy
Pyeloplasty
Endoscopic
Endopyelotomy
Balloon dilatation
Laparoscopic
Nephrectomy
If non fuctioning kidney

20. Posterior Urethral Valves
Thin membrane obstructing the urethra distal to the verumontanum
This cause proximal urethral dilatation, severe bladder trabeculation and bilateral hydronephrosis

21. Presentation
The more severe the obstruction the earlier the patient presents
60% presents before 1 year of age
Neonates presents with
UTI
Acute renal failure
Failure to thrive
Respiratory distress
Palpable kidneys
Urinary ascites
Older children presents with
Recurrent UTI
Overflow incontinence
Chronic renal failure

22. In the acute setting Acute management Resuscitation Urethral catheter
Fluids
Electrolytes
Correct Acid base balance
Treat UTI
Urethral catheter
Will relieve obstruction
This will allow urosepsis and renal failure to resolve

23. Diagnosis Ultrasound VCUG Will show Confirms the diagnosis
bilateral hydronephrosis and hydroureter
Thickened bladder wall
Dilated posterior urethra
VCUG
Confirms the diagnosis
Trabeculated bladder
VUR (Secondary reflux)

24. Treatment Surgical treatment
Endoscopic valve ablation (As soon as condition stabilized)
Vesicostomy if persistent UTI or poor renal function
Despite correct treatment 50% of these children will end up in end stage renal failure after puberty