Urinary Infection in Children & Vesico Ureteric Reflux

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. Host Bacteria What is the pathogenesis?

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 10-14 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 6m, re evaluate No reflux; no scar < 2 yrs 6m, 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. UTI VUR Scarring 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

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 • 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!