When It’s Not Just a Urinary Tract Infection

By Kropp, Bradley P Klein, Jake

Urinary tract infections (UTIs) in small children have a variety of causes, including poor toilet-training habits. Often, these conditions resolve with a course of antibiotics and a simple review of good bathroom habit practices, such as always wiping from front to back and voiding (urinating) completely. In some cases, particularly when urinary tract infections are recurrent and involve fevers (also know as febrile UTIs), they may be a symptom of a potentially serious urinary condition in children. The condition, known as vesicoureteral reflux (VUR), affects approximately one percent of all children. It occurs when urine flows the wrong way through the ureters, or the tubes that connect the kidneys to the bladder. Ordinarily, urine flows in one direction only: from the kidneys through the ureters to the bladder. In children with VUR, however, a malformation of the ureters allows urine to flow backwards from the bladder through one or both ureters and up towards the kidneys.

There are two causes of VUR: the more common, known as primary VUR, is present at birth and occurs during fetal development. This form is an anatomical malfor mation of the area where the ureter enters the bladder. Less common is secondary VUR, which is caused by an obstruction in the bladder or urethra and generally the result of high-pressure bladder situations such as neurogenic bladders, posterior urethral valves (found in males), or simply because of bad toileting habits such as “holding” urine. Both types of VUR cause retrograde, or backwards, flow of urine towards the kidneys.

VUR tends to run in families: if a parent has VUR, up to half of his or her children will also have it. If a child has VUR, as many as one-third of his or her siblings will also have it.

When VUR is present alone, it has no symptoms. However, the diagnosis of reflux is often confirmed during the complete work-up of a urinary tract infection. The symptoms of a urinary tract infection can include, but are not limited to, fever, dysuria (burning with urination), back or flank pain, urinary urgency or frequency, cloudy or foul-smelling urine, nausea, and vomiting.

If left untreated, serious consequences of VUR include kidney infections (pyelonephritis) that can occur when infected urine flows back into the kidneys. These infections can damage the kidneys with renal scarring which can eventually lead to poor kidney function and high blood pressure. For this reason, VUR should be diagnosed and treated as early as possible. VUR is usually diagnosed after a child has a urinary tract infection and sometimes from abnormal prenatal ultrasound findings. The average age at diagnosis is three to four years but it may be diagnosed at any age, even in newborn babies or older children. A health care professional will ask about the history of your child’s symptoms, do a physical examination and may elect to perform several tests if VUR is suspected.

One such test is called a voiding cystourethrogram (VCUG) or NCG (nuclear cystogram), often referred to as “voiding studies.” These are X-rays of the bladder where a thin plastic tube called a catheter is inserted into the urethra. Fluid containing an X-ray dye or radioactive tracer is then injected through the tube until the bladder is full, and then the child is asked to urinate. Pictures of the bladder reveal whether the dye goes backwards up to one or both kidneys. These tests usually take 15 to 20 minutes.

The VCUG is usually done as a first-line study because it determines the severity of the condition and provides optimal imaging of the anatomy. The severity is determined using an accurate grading system of grade I (mild) to grade V (severe). Nuclear cystograms (NCG), on the other hand, are best utilized as follow-up studies because they expose the patient to less radiation. Although NCG does not allow for precise grading (i.e. mild-moderate-severe) or good imaging of the anatomy, it will show if reflux is present or not.

When treating VUR, the primary goal is the rapid and effective prevention of febrile UTIs to ultimately reduce the risk of long- term consequences. Milder grades of VUR may resolve spontaneously. However, the more severe the VUR, the less likely it will go away on its own. Half of the children affected require treatment. There are three treatment options for VUR:

* Antibiotics may be used to prevent UTIs until the VUR resolves on its own. This preventative treatment may take several years, and parents must comply with the strict dosing schedule. Antibiotics are considered “first line therapy” for all but the most severe grades of reflux. No long-term complications from daily antibiotic usage have been reported. However, bacterial resistance has been recognized as a consequence of antibiotic treatment.

* There are two types of surgeries performed to cor rect VUR.

1. Open surgery can repair the valve in the ureter to prevent reflux from occurring. This treatment is highly effective, but usually requires a short hospitalization, accompanied with pain and recovery time, which is typical of any open surgical procedure.

2. Endoscopic treatment involves injecting a gel-type substance where the ureter joins the bladder, creating a cushion that effectively prevents the urine from flowing back. Currently, DEFLUX is the only approved endoscopic VUR treatment in the United States. DEFLUX is indicated for VUR grades II through IV. This procedure is performed on an outpatient basis and is usually associated with minimal pain and recovery time.

In summary, UTIs DO NOT cause reflux, and reflux DOES NOT cause UTIs. However, all parents and their children can benefit from identification of UTI risk factors and an understanding of optimal bowel and bladder habits as a lifestyle commitment. Your physician can help you to identify and correct any potentially harmful elimination habits such as holding or straining. In addition, parents should be aware of the importance of maintaining good genital hygiene, encouraging proper “voiding” posture, and of promoting optimal fluid intake.

By Bradley P. Kropp, Mb and Jake Klein, MS, CPNP

Bradley P. Kropp, MD, is the Chief of the Pediatric Urology Service at the Children’s Hospital of Oklahoma. He is certified by the Board of Urology and fellowship trained in pediatric urology. He has published numerous articles in various journals and has presented at many national meetings. He is the past President of the Society of Fetal Urology. His major clinic focus is in the reconstruction of exstrophy and neurogenic bladders. He is a member of the American Academy of Pediatrics and the Society for Pediatric Urology.

Jake Klein is the clinic manager as well as a full-time Certified Pediatric Nurse Practitioner at the Pediatric Urology Clinic in Children’s Hospital located on the Health Sciences Center campus in Oklahoma City. He specializes in voiding dysfunction and all other pediatric urology problems. He is an active member of the Pediatric Urology Nurses Specialists, and many other organizations.

Copyright Pediatrics for Parents, Inc. Sep 2007

(c) 2007 Pediatrics for Parents. Provided by ProQuest Information and Learning. All rights Reserved.