Common Ut Concerns In Children
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COMMON URINARY TRACT COMMON URINARY TRACT CONCERNS IN CHILDRENCONCERNS IN CHILDREN
Waldo C. Feng M.D.,Ph.D.Waldo C. Feng M.D.,Ph.D.Children’s Urology AssociatesChildren’s Urology Associates
Las Vegas, NevadaLas Vegas, Nevada
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Urinary Tract Infections in Urinary Tract Infections in ChildrenChildren
• Presentation - Presentation - What is this?What is this?
• EpidemiologyEpidemiology - Who and When? - Who and When?
• PathogenesisPathogenesis - Why? - Why?
• MicrobiologyMicrobiology - The Culprits - The Culprits
• ManagementManagement - What We Do and Why - What We Do and Why
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The Child With UTIThe Child With UTI
• UTI One of the Most Common UTI One of the Most Common Bacterial InfectionsBacterial Infections
• 8 Million Office Visits8 Million Office Visits
• 1.5 Million Hospital Discharges1.5 Million Hospital Discharges
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UTI IncidenceUTI Incidence
Kunin, 1998
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PRESENTATIONPRESENTATION
• Infants and ToddlersInfants and Toddlers
• *Non-specific Signs*Non-specific Signs– IrritabilityIrritability– FeverFever– Failure to ThriveFailure to Thrive– Nausea / VomitingNausea / Vomiting– DiarrheaDiarrhea– HematuriaHematuria
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PRESENTATIONPRESENTATION• School Age ChildrenSchool Age Children
• IrritabilityIrritability• ListlessnessListlessness• Pain with VoidingPain with Voiding• Frequency / UrgencyFrequency / Urgency• Foul Odor to UrineFoul Odor to Urine• Unexplained FeverUnexplained Fever• New Onset IncontinenceNew Onset Incontinence• Abdominal / Flank PainAbdominal / Flank Pain
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Localization of InfectionLocalization of Infection• Cystitis = Cystitis =
Inflammation of the Inflammation of the BladderBladder
• Symptoms / SignsSymptoms / Signs– Gradual Onset of FeverGradual Onset of Fever– Irritative Voiding Irritative Voiding
SymptomsSymptoms– Suprapubic / Urethral Suprapubic / Urethral
DiscomfortDiscomfort
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• Pyelonephritis = Pyelonephritis = Infection of KidneyInfection of Kidney
• Symptoms / SignsSymptoms / Signs– Abrupt Onset of Abrupt Onset of
FeverFever– Shaking ChillsShaking Chills– Flank PainFlank Pain– Nausea / VomitingNausea / Vomiting
Localization of InfectionLocalization of Infection
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Pathogenesis - UTIPathogenesis - UTI
Ascending Route of UTIAscending Route of UTI
° Bacterial ColonizationBacterial Colonization
° Migration to Periurethral RegionMigration to Periurethral Region
° Migration into BladderMigration into Bladder
° Growth in UrineGrowth in Urine
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Pathogenesis - PyelonephritisPathogenesis - Pyelonephritis
• Bacterial Ascent to Bacterial Ascent to KidneyKidney
• Colonization of Renal Colonization of Renal MedullaMedulla
• Focal Abcess Focal Abcess FormationFormation
• BacteremiaBacteremia• Kidney Re-infectionKidney Re-infection
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Bacterial FactorsBacterial Factors
• Virulence FactorsVirulence Factors– Cell Wall AntigensCell Wall Antigens– Serum ResistanceSerum Resistance– Hemolytic CapabilityHemolytic Capability– Growth DynamicsGrowth Dynamics– Iron ScavengingIron Scavenging
• Adherence FactorsAdherence Factors– P FimbriaeP Fimbriae– Type 1 FimbriaeType 1 Fimbriae– DR FimbriaeDR Fimbriae
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Host Defense FactorsHost Defense Factors
• Urine pH / Vaginal pHUrine pH / Vaginal pH
• Local IgA AntibodiesLocal IgA Antibodies
• Voiding MechanicsVoiding Mechanics
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UTI Risk FactorsUTI Risk Factors
Voiding Voiding DysfunctionDysfunction
Urinary Tract Urinary Tract AbnormalitiesAbnormalities
Other Medical Other Medical ConditionsConditions
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UTI Risk FactorsUTI Risk Factors
• ForeskinForeskin• Constipation ?Constipation ?• VUR in Sibling ?VUR in Sibling ?
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Common PathogensCommon Pathogens
• The CulpritsThe Culprits– Escherichia ColiEscherichia Coli– EnterococcusEnterococcus– P. aeruginosaP. aeruginosa– Klebsiella sp.Klebsiella sp.– Proteus sp.Proteus sp.– Enterobacter sp.Enterobacter sp.– Coag-negative staphCoag-negative staph– Staph aureusStaph aureus– Candida sp.Candida sp.
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Management of UTIManagement of UTI
• Alleviate Acute MorbidityAlleviate Acute Morbidity
• Prevent Long-term SequelaePrevent Long-term SequelaeRenal ScarringRenal ScarringHypertensionHypertensionEnd-Stage Renal DiseaseEnd-Stage Renal Disease
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Renal Scarring - InfectionRenal Scarring - Infection
• First InfectionFirst Infection
• 20-35% Children20-35% Children
• 46% Neonates46% Neonates
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Renal ScarringRenal Scarring
• 9% 1 Episode9% 1 Episode
• 58% 4 Episodes58% 4 Episodes
• May Take 1-2 Years May Take 1-2 Years To DevelopTo Develop
• Majority Occur < 5 Majority Occur < 5 Years of AgeYears of Age Bellman, 1995
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UTI ManagementUTI Management
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Management - UTIManagement - UTI
• DiagnosisDiagnosis– Culture MethodsCulture Methods– Screening TestsScreening Tests– Anatomic / Functional EvaluationAnatomic / Functional Evaluation
• TreatmentTreatment– Age of PatientAge of Patient– Severity of InfectionSeverity of Infection– Prior History of UTIPrior History of UTI
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Screening TestsScreening Tests
• Microscopic AnalysisMicroscopic Analysis
• Urine Dipstick AnalysisUrine Dipstick Analysis– Sensitivity 80-90% / Specificity 60-98%Sensitivity 80-90% / Specificity 60-98%– Leukocyte EsteraseLeukocyte Esterase– NitritesNitrites
• First Voided Urine BestFirst Voided Urine Best• Dietary nitratesDietary nitrates
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Culture MethodsCulture Methods
• Clean Voided SpecimenClean Voided Specimen– 80% Accuracy80% Accuracy
• Bagged SpecimenBagged Specimen
• Catheterized SpecimenCatheterized Specimen
• Suprapubic AspirationSuprapubic Aspiration
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Specimen CollectionSpecimen Collection• Newborns & InfantsNewborns & Infants
– Bagged SpecimensBagged Specimens– Suprapubic AspirationSuprapubic Aspiration– Urethral CatheterizationUrethral Catheterization
• ToddlersToddlers– Bagged SpecimensBagged Specimens– Clean VoidClean Void– Urethral CatheterizationUrethral Catheterization
• School Age ChildrenSchool Age Children– Midstream Clean CatchMidstream Clean Catch
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Quantitative Urine CultureQuantitative Urine Culture
• The SpecimenThe Specimen - - *Midstream Clean Catch Specimen*Midstream Clean Catch Specimen
<10,000 CFU Probable Contaminant<10,000 CFU Probable Contaminant >100,000 CFU>100,000 CFU Significant Colony Count Significant Colony Count
• Enteric Gram Negative BacteriaEnteric Gram Negative Bacteria
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Anatomic / Functional Anatomic / Functional EvaluationEvaluation
• GoalsGoals– Assess risk of Assess risk of
DamageDamage– Assess Presence Assess Presence
of Damageof Damage– Identify Identify
Complicating Complicating FactorsFactors
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Evauation of UTIEvauation of UTI
• Physical ExamPhysical Exam• Imaging StudiesImaging Studies
– When to Evaluate?When to Evaluate?– How To Evaluate?How To Evaluate?– RUSRUS– IVPIVP– DMSA ScanDMSA Scan– CystographyCystography
– RNCRNC
– VCUGVCUG
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UTI Imaging StudiesUTI Imaging Studies
GirlsGirls
• Initial StudiesInitial Studies– USNUSN– VCUGVCUG
• Follow-up StudiesFollow-up Studies– USNUSN– VCUGVCUG
BoysBoys
• Initial StudiesInitial Studies– USNUSN– VCUGVCUG
• Follow-up StudiesFollow-up Studies– USNUSN– VCUGVCUG
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UTI - UltrasoundUTI - Ultrasound
• 2-3 % Yield2-3 % Yield Obstructive Obstructive UropathyUropathy
Bellman, 1995
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UTI - Voiding StudyUTI - Voiding Study
• VCUG For 1st VCUG For 1st StudyStudy
• Pyelonephritis Pyelonephritis Associated With Associated With Vesico-Ureteral Vesico-Ureteral Reflux Reflux 50%50%
Bellman, 1995
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Vesico-Ureteral RefluxVesico-Ureteral Reflux
ManagementManagement
• Medical Medical
• SurgicalSurgical
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Vesico-Ureteral RefluxVesico-Ureteral Reflux
Surgical Surgical ManagementManagement
• Breakthrough UTIBreakthrough UTI• Poor CompliancePoor Compliance• Failure of VUR to Failure of VUR to
ResolveResolve
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Medical Management Of VURMedical Management Of VUR
• SuppressiveSuppressive Antibiotic Therapy Antibiotic Therapy
• +/- Screening Urinalysis+/- Screening Urinalysis
• Treat Treat Voiding DysfunctionVoiding Dysfunction
• Serial Imaging StudiesSerial Imaging Studies
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Voiding DysfunctionVoiding Dysfunction
• Appears to Prolong VURAppears to Prolong VUR– Treatment Resolution RatesTreatment Resolution Rates
• Increases risk of Urinary Tract Increases risk of Urinary Tract InfectionInfection– 23% Without UTI23% Without UTI– 65% With UTI65% With UTI
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Voiding DysfunctionVoiding Dysfunction
• Urge Urge IncontinenceIncontinence
• Infrequent Infrequent VoidingVoiding ““Lazy Bladder”Lazy Bladder”
• Nonneurogenic Nonneurogenic Neurogenic Neurogenic BladderBladder
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Voiding Dysfunction - VURVoiding Dysfunction - VUR
• 1/3 to 1/2 of Children With UTI & VUR1/3 to 1/2 of Children With UTI & VUR
• Not Systematically ReportedNot Systematically Reported
• ? Relationship To VUR? Relationship To VUR
• Increases Risk of Breakthrough UTIIncreases Risk of Breakthrough UTI
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Assessment of Voiding Assessment of Voiding PatternsPatterns
• Frequency of UrinationFrequency of Urination• Frequency / Amount of Frequency / Amount of
IncontinenceIncontinence• Stream QualityStream Quality• Time Spent VoidingTime Spent Voiding• Posturing ManeuversPosturing Maneuvers
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Bladder Retraining ProgramBladder Retraining Program
• Timed VoidingTimed Voiding
• Relaxation Relaxation TechniquesTechniques
• Biofeedback TherapyBiofeedback Therapy
• Behavior ModificationBehavior Modification
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Role of ConstipationRole of Constipation
• Voiding Voiding DysfunctionDysfunction
• Affects 10-40%Affects 10-40%
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ConstipationConstipation
• Toileting ScheduleToileting Schedule• Evaluate DietEvaluate Diet• Healthy Snacks Healthy Snacks
AvailableAvailable• Mineral Oil / Stool Mineral Oil / Stool
SoftenersSofteners
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VUR - Sibling ScreeningVUR - Sibling Screening
• Incidence in General Population < 1%Incidence in General Population < 1%
• 34% In Siblings of Index Patients34% In Siblings of Index Patients
• History of UTIHistory of UTI– 25% of Siblings With VUR25% of Siblings With VUR– 75% Asymptomatic75% Asymptomatic
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VUR - Sibling ScreeningVUR - Sibling Screening
• Rate of Renal Scarring Lower in Rate of Renal Scarring Lower in SiblingsSiblings
• Higher Rate of VUR & Renal Scarring Higher Rate of VUR & Renal Scarring < 18 months old< 18 months old
• Risk of Renal Scarring At Early AgeRisk of Renal Scarring At Early Age
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SummarySummary• UTI in Children - UTI in Children -
Spectrum of Spectrum of DiseaseDisease– SymptomsSymptoms
– AgeAge
• Multifactorial EtiologyMultifactorial Etiology
• Diagnosis & Diagnosis & ManagementManagement
• Tailor Treatment Tailor Treatment AccordinglyAccordingly
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RecommendationsRecommendations
First Febrile UTIFirst Febrile UTI
• Presumptive Dx - Presumptive Dx - PyelonephritisPyelonephritis
• ABX SuppressionABX Suppression• Imaging StudiesImaging Studies
– USNUSN– VCUGVCUG– +/- DMSA Scan+/- DMSA Scan
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SummarySummary
• Evaluation and Evaluation and Treatment Treatment Strategies for UTI Strategies for UTI are Dynamicare Dynamic
• Significant Significant Variation in Variation in Management Management ExistsExists
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THE END?THE END?