A 20-year study of persistence of lower urinary tract symptoms and urinary incontinence in young women treated in childhood

ObjectiveTo determine whether urinary incontinence (UI) and lower urinary tract symptoms (LUTS) persist over years, patients treated for UI and LUTS in childhood were re-evaluated in adulthood.Materials and methodsForty-seven women (cases) treated in childhood for daytime UI/LUTS (group A) and nocturnal enuresis (group B) self-completed (average age: 24.89 ± 3.5 years) the International Consultation on Incontinence Questionnaire for Female with LUTS (ICIQ-FLUTS). ICIQ-FLUTS was self-administered to 111 healthy women (average age: 23 ± 5.1 years) from a nursing school as a control group. Data obtained from ICIQ-FLUTS and quality of life (QoL) score (0–10) were compared (Fisher's exact test) between patients and controls, and between group A (n = 28) and group B (n = 19).ResultsPrevalence of LUTS was higher in patients than in controls. The difference between patients and controls was statistically significant (p = 0.0001) for UI (34% vs. 7%) and feeling of incomplete bladder emptying (49% vs. 28%). QoL score was >5 in 59% of patients and 1% of controls (p = 0.0001). No significant differences were found between groups A and B.ConclusionsUI and LUTS are confirmed in young women who suffered for the same condition in childhood. Longitudinal studies are needed to assess if these symptoms persist or are newly onset.     

Imaging the urinary tract in children with urinary tract infection

Aim: To evaluate whether ultrasonography (US) alone is sufficient in imaging the urinary tract in 1185 children with urinary tract infection (UTI). Methods: The reports on US and voiding cystourethrography (VCUG) were reviewed. Results: Initial US was normal in 861/1185 patients (73%). VCUG revealed abnormal findings in 285/861 (33%), of which grade III–V vesicoureteral reflux (VUR) comprised 97 cases (11%). During follow‐up, VUR had resolved in 88/97 (91%) patients: in 50/57 (88%) patients without active treatment for VUR, in 27/29 (93%) with endoscopic and in 11/11 (100%) with open surgery for VUR. During follow‐up, 11/97 patients (11%) had developed new renal scarring detectable in US, but no renal impairment occurred. Except for VUR, VCUG showed nonobstructive urethral valves in two infant boys with normal initial US. Thus, in 861 children with normal initial US, 40 patients with grade III–V VUR and two patients with significant nonreflux pathology may have benefited from surgical treatment, giving the total number of possibly missed pathological finding in 42/861 (4.9%) cases if VCUG had not been performed. Conclusion: We suggest that children with UTI could be examined using US alone and to use VCUG only after additional indications.     

Ultrasonography after the first febrile urinary tract infection in children

The importance of ultrasonography after the first febrile urinary tract infection has been recently challenged. The aim of this study was to evaluate the role of ultrasonography in detection of significant non-reflux abnormalities in the kidneys and the urinary tract, and to determine whether these findings influence treatment in these children. The clinical data and ultrasonography results of 155 children admitted to a university hospital with the first febrile urinary tract infection were analysed retrospectively. Renal ultrasonography was abnormal in 23 patients (14.8%). The major portion of these patients (81%) were younger than 2 years of age. Management of nine of these patients was changed based primarily on ultrasonography findings. Four of these patients were treated operatively. Conclusion: Our findings indicate that ultrasonography performed after the first urinary tract infection may offer clinically important information about non-reflux abnormalities in the kidneys and urinary tract that can affect the management of children with these complications.     

Radiological evaluation of the urinary tract in children with urinary infection

Objective: This article in to study the association of structural abnormalities of the urinary tract in children with urinary tract infection (UTI) using ultrasound examination.Methods : 262 children with culture proven urinary tract infection were studied. Antibiotics were given as per sensitivity pattern. All children had an ultrasound of the abdomen done within 3 weeks. A micturating cystourethrogram (MCU) was done in those with abnormalities of the lower urinary tract detected on ultrasound, as well as in those who had recurrence of infection, after a normal ultrasound. IVU and renal isotope scans were done in selected cases.Result : All children were followed up until one year after the study period. Fifty-four patients had an underlying urinary tract anomaly; 42 were picked up by ultrasound and 12 by MCU. 22.9% of males and 15.9% of females had anomaly of the urinary tract. Children less than 2 years had the highest incidence of anomalies.Conclusion : Pelviureteric junction obstruction with hydronephrosis, vesicoureteric reflux and non-refluxing megaureter are the major anomalies picked up. 20% of children with urinary tract infections have an underlying structural abnormality of the urinary tract, three-fourth of which are picked up on ultrasound. An ultrasound abdomen is recommended in all children after the first UTI. In addition, an MCU is also indicated in all boys below 2 years with UTI, since one-third of anomalies will be missed if only ultrasound is done.     

Advances in management of urinary tract infections

Urinary Tract Infections (UTI) are a common bacterial infection in children. The diagnosis of UTI is very often missed in young children due to minimal and non-specific symptoms. The developing renal cortex in young children is vulnerable to renal scarring resulting in hypertension and chronic renal failure. A clinically suspected case of UTI should be defined and documented with urine culture report. After the diagnosis of UTI, its category should be defined. It will guide for proper radioimaging evaluation, choice of antimicrobial agent, duration of treatment, need of chemoprophylaxis etc. Even a single confirmed UTI should be taken seriously. Rational use of modern radioimaging for proper evaluation is essential. UTI in neonates, nosocomial UTI and UTI due to ESBL producing organisms are special situations, to be identified and managed with advanced therapy promptly and appropriately.     

Management of urinary tract infections

Urinary tract infection (UTI) is common in childhood. It may result in long-term complications due to renal scaring. Younger children are at higher risk of renal scarring. The diagnosis of UTI is based on urine culture. The bacterial count for diagnosis of UTI depends on the method of urine collection. Urinalysis is useful for making a presumptive diagnosis of UTI and allows initiation of empirical treatment in high-risk patients, after urine culture has been obtained. The treatment of UTI is guided by the severity of illness and age of the patient. Following a UTI, investigation should be performed to identify an underlying urinary tract anomaly. Recurrence of UTI occurs in 30–50% children. Important predisposing factors include VUR, urinary tract obstruction, voiding dysfunction and constipation. Vesicoureteric reflux (VUR) is seen in 30–50% children with UTI. The cornerstone of management of VUR is long-term antibiotic prophylaxis, which has been found to be as effective as surgical reimplantation.     

Incomplete bladder emptying is associated with febrile urinary tract infections in infants

ObjectiveTo investigate lower urinary tract dysfunction in pre-toilet trained infants with and without history of febrile UTI (f-UTI).Materials and MethodsPre-toilet trained infants with f-UTI (Group 1) from pediatric nephrology and urology clinics, and those without f-UTI (Group 2) from infant-care centers were enrolled for the present study. Infants in Group 1 underwent four-hourly (4-H) observations for at least one month after treatment for UTI. Voided volume (VV) and post-void residual urine (PVR) were measured by weighting diaper and suprapubic ultrasound after finishing voiding, respectively. Average PVR was defined as the mean value of PVR during 4-H observation. Interrupted voiding was defined as two or three voidings within 10 min. Voiding efficiency was defined as VV/(VV + PVR).ResultsThe mean ages of Group 1 (n = 64) and Group 2 infants (n = 56) were 10.6 ± 7.5 months vs 10.2 ± 5.1 months, respectively (p = 0.70). Group 1 infants had significantly higher voiding frequency (3.0times ± 1.2 vs 2.6times ± 0.9, p = 0.04), average PVR (14.5 ml ± 14.2 vs 8.9 ml ± 8.8, p < 0.01) and lower voiding efficiency (71.2% ± 20.5 vs 80.2% ± 18.5, p = 0.01) than Group 2. ROC curve analysis showed that the optimal cutoff values for PVR and voiding efficiency to differentiate Group 1 and Group 2 infants were 10 ml and 80%, respectively. Group 1 infants had significantly more repeat elevated PVR (≧ 10 ml) and repeat low voiding efficiency (≦ 80%) than Group 2 (44.8% vs 22.4%, p = 0.03; 62.0% vs 28.6%, p < 0.01, respectively).ConclusionPre-toilet trained infants with f-UTI were associated with elevated PVR and lower voiding efficiency than normal controls.     

Prenatally diagnosed urinary tract abnormalities: long-term outcome

The long-term outcomes of prenatally detected uropathies are poorly documented. Limited data on fetal intervention show a possible reduction in early mortality from pulmonary hypoplasia, but no beneficial effect on long-term prognosis for renal function. Prenatally detected vesicoureteric reflux (VUR) is characterised by males with high-grade primary reflux, who are at long-term risk of renal impairment. Prenatal diagnosis and surgical intervention have contributed to a reduction in long-term morbidity in children with pelviureteric junction (PUJ) obstruction. By the same token, many children have almost certainly undergone unnecessary early pyeloplasty for an obstruction that would have resolved spontaneously. Multicystic dysplastic kidney (MCDK) carries a low (1%) risk of hypertension in childhood. The limited evidence on the long-term outcome of mild dilatation (pelvicaliectasis) indicates this is a largely innocent finding, which carries no increased risk of morbidity.     

Fetal lower urinary tract obstruction

Fetal lower urinary tract obstruction affects 2.2 per 10 000 births. It is a consequence of a range of pathological processes, most commonly posterior urethral valves (64%) or urethral atresia (39%). It is a condition of high mortality and morbidity associated with progressive renal dysfunction and oligohydramnios, and hence fetal pulmonary hypoplasia. Accurate detection is possible via ultrasound, but the underlying pathology is often unknown. In future, magnetic resonance imaging (MRI) may be increasingly used alongside ultrasound in the diagnosis and assessment of fetuses with lower urinary tract obstruction. Fetal urine analysis may provide improvements in prenatal determination of renal prognosis, but the optimum criteria to be used remain unclear. It is now possible to decompress the obstruction in utero via percutaneous vesico-amniotic shunting or cystoscopic techniques. In appropriately selected fetuses intervention may improve perinatal survival, but long-term renal morbidity amongst survivors remains problematic.     

Late onset jaundice and urinary tract infection in neonates

Objective To determine the prevalence and the associated parameters of urinary tract infection (UTI) in infants with late onset jaundice. Methods This prospective analytic study was conducted among 400 cases, selected by simple sampling from neonates with late onset jaundice admitted in two referral hospitals of Isfahan during a 9-month period. The information including the age, sex and feeding type, as well as the results of physical examination, treatment, radiology studies, etc were recorded. The etiology of jaundice was assessed by laboratory tests. Urine analysis and urine culture were performed for all subjects. XZ and t-test were used for analysis of the data in-SPSS software. Results Of the 400 icteric neonates, 147 (36.8%) were female and 253 (63.3%) were male; 23 (5.8%) were diagnosed to have UTI, 5 cases (1.3%) had G6PD deficiency, 19 (4.8%) had dysmorphic red blood cell and 3(0.75%) had ABO or RH incompatibility. The relation between the type of feeding, circumcision and UTI was significant (P<0.05). Of the 23 neonates with UTI, 4 cases (17.39%) were found to have urogenital abnormality. Conclusion UTI was found in 5.8% of infants with late onset jaundice. The study revealed significant association between breast feeding, circumcision and lower prevalence of UTI in icteric neonates. It is suggested that evaluation for UTI should be considered as a screening test in all cases of neonatal late onset jaundice.     

儿童泌尿系统感染诊治进展

泌尿系统感染(UTI)是儿科最常见的细菌感染性疾病之一,约30%的婴幼儿在初次感染6~12个月反复发作。而在有泌尿系统发育畸形的儿童中,约30%的患儿以UTI为首发表现,故UTI可能是潜在肾脏结构异常的前哨事件。婴幼儿UTI常并膀胱输尿管反流等先天性尿路畸形,对于反复感染的高危患儿,易出现肾脏损害及肾瘢痕,进而导致终末期肾病。因此,早期识别、及时治疗和合理管理对改善预后十分重要。现总结近年来国内外相关文献,以期为儿童UTI的诊治提供临床参考。     

Antenatally detected urinary tract abnormalities: changing incidence and management

To define the incidence of urinary tract abnormalities detected by antenatal ultrasound and assess changes in postnatal management we conducted a retrospective survey using data bases of the nephro-urology unit, obstetric ultrasound and perinatal pathology departments. The birth population (105,542) of the two Nottingham teaching hospitals between January 1984 and December 1993 was divided into two 5-year cohorts, 1984–1988 and 1989–1993. Detailed fetal scanning at 18–20 weeks gestation was introduced in 1989. During this 10-year period, 201 abnormalities of the urinary tract were noted with a 2:1 male to female ratio. The incidence of abnormalities in the first 5 years was 1 in 964 compared to 1 in 364 in the last 5 years. There was a significant increase in the number detected before 20 weeks gestation (12% in 1984–1988 compared to 62% in 1989–1993). Despite the increased incidence of abnormalities detected, the termination rate remained static between the two 5-year cohorts. Only 3 fetuses had intra-uterine intervention and 173 were live-born. Eight infants subsequently died in association with other major congenital abnormalities. The incidence of transient abnormalities (antenatal dilatation with no abnormality noted on postnatal ultrasound) increased from 6% in 1984–1988 to 18% in the 1989–1993 cohort. A more conservative approach to postnatal management is reflected by 71% of infants having operations between 1984 and 1988 compared to 35% in 1989–1993. Conclusion The advent of detailed fetal scanning at 18–20 weeks gestation has significantly increased the detection rate of urinary tract abnormalities with no significant increase in pregnancy termination rates. The need for antenatal intervention is a rare event and most problems can be managed conservatively both pre- and postnatally. Received: 16 April 1997 and in revised form: 10 November 1997 / Accepted: 10 November 1997     

Intramuscular antibiotic treatment of urinary tract infection

Objective: This study had been carried out to investigate the effects of intramuscular daily single dose antibiotic treatment during five days in the outpatient clinics in children having lower UTI and to observe the effects to the disease course in infants and toddlers.Methodology: 36 children (12 boys) at the ages of between 5–68 months were enrolled into the study. Regarding the antibiogram suitability, single dose ceftriaxon or amikacin is prescribed to the patients for five days.Result: In the urine culturesE. Coli was most commonly isolated. There was correlation between leukocytosis and insufficient weight gain (p< 0.05). A correlation was also noted between recurrence of the disease and urinary tract abnormalities detected on the ultrasonography (p< 0.05). Reenfection were detected in 1 of the infants and in 2 of the older children. There was no correlation between the recurrence and the therapy given.Conclusion: We consider that five-day intramuscular antibiotic therapy could be effective in the treatment of lower UTI and it can be recommended as a safe treatment modality in patients representing unwillingness to come to follow-up visits     

小儿泌尿系感染277例临床分析

目的探讨小儿泌尿系感染的临床特点及致病菌的分布和耐药情况,为临床诊断治疗提供依据。方法对1998—2006年首都医科研究所附属儿童医院肾脏病房收治的277例泌尿系感染患儿的临床特点、实验室检查、治疗及转归进行回顾性分析。结果145例尿培养前未应用过药物的患儿其尿培养阳性率为62.07%,132例培养前应用过药物的患儿其阳性率为20.45%,两者差异有统计学意义(P<0.05)。尿培养结果中大肠埃希菌有94例,对丁胺卡那霉素和头孢西丁的敏感率均在90%以上。结论抗生素的应用会大大降低尿培养的阳性率。大肠埃希菌为泌尿系感染的常见致病菌,头孢西丁可作为小儿泌尿系感染的首选用药。对首次发病的泌尿系感染患儿进行相应的影像学检查以排除一些潜在的病因是十分必要的。     

Spondylocostal dysostosis and urinary tract anomaly: Definition and review of an entity

A two-year-old girl with spondylocostal dysostosis and urinary tract anomalies is described. Genetic counselling to the healthy non-consanguineous parents is based on the hypothesis of autosomal recessive inheritance. At birth this type of spondylocostal dysostosis can be differentiated radiographically from related conditions by the severe and generalized anomaly of the entire vertebral column, and by the typical configuration of the posteriorly-fused ribs. Only the cardinal clinical features of a short trunk and a short, immobile neck are consistently present in all patients. In one group of patients the severe thoracic malformation and lordosis contribute to cardiopulmonary problems with a fatal outcome in early infancy. The roentgenographic changes are less marked in other patients, whose subsequent clinical course is usually without major problems but remains at present insufficiently known.Supported in part by grant No. 20.057 to J. G. Leroy from the Belgian NGWO, Brussels, Belgium     

Staphylococcus saprophyticus urinary tract infections in children

Staphylococcus saprophyticus commonly causes urinary tract infection (UTI) in young women: in males it is found mainly in the elderly. In this studyS. saprophyticus UTI occurred in 59 children (45 girls and 14 boys) below 16 years of age, of whom 20 were less than 13 years of age. The common presentation was dysuria and flank or back pain whereas fever 38.5°C was rare. Radiological investigation performed in 63% of the children revealed no anomalies of importance. Children withS. saprophyticus UTI appear to constitute a group with a low frequency of urinary tract anomalies and with a low risk of UTI caused by other bacteria.     

Uncomplicated duplex kidney and DMSA scintigraphy in children with urinary tract infection

Background Renal duplication is the most common malformation of the urinary tract and is frequently seen among children with urinary tract infection (UTI). Objective To evaluate problems in the interpretation of dimercaptosuccinic acid (DMSA) scintigraphy and to establish the range of relative function in uncomplicated unilateral duplication. Materials and methods Retrospective analysis of 303 children less than 2 years of age with first time non-obstructive urinary tract infection investigated by both urography and DMSA scintigraphy. At DMSA scintigraphy, renal lesions and/or relative function below 45% was considered abnormal. Urography was used as reference for the diagnosis of duplication. Results Duplex kidneys were found in 22 of 303 patients (7%). Of the 16 children with unilateral duplication, 10 had bilaterally undamaged kidneys with a range of relative function varying between 51% and 57% in the duplex kidney. In two of the children with unilateral duplication the imaging results were discordant. Conclusion There was risk of underdiagnosis as well as overdiagnosis of renal damage at scintigraphy. Although it is important to be aware of this risk, the rate of misinterpretation was low. A range of 51% to 57% can be used as the limit for normality of the relative function of a unilateral duplex kidney.     

Clinical predictors of positive urine cultures in young children at risk for urinary tract infection

BACKGROUND:

Urinary tract infections (UTIs) are a common source of bacterial infection among young febrile children. The diagnosis of UTI is challenging because the clinical presentation is not specific.

OBJECTIVE:

To describe clinical predictors to identify young children needing urine culture for evaluation of UTI.

METHODS:

Retrospective cohort study of all children younger than two years of age (719 hospital visits for 545 patients) suspected of having a UTI during a 12-month period. The outcome was UTI, defined as a catheterized urine culture with pure growth of 10⁴ colonies/mL or greater, or suprapubic aspiration culture with 10³ colonies/mL or greater. Candidate predictors included demographic, historical and physical examination variables.

RESULTS:

The medical records of 545 children younger than two years of age were reviewed. Forty-six per cent were girls. Mean age was 9.1 months (SD 7 months). Four variables were found to predict UTI: absence of another source of fever on examination (odds ratio [OR]=41.6 [95% CI, 8.8 to 197.4]), foul smelling urine (OR=19.7 [95% CI, 5.7 to 68.2]), white blood cell count greater than 15,000/mm³ (OR=4.3 [95% CI, 2.0 to 9.3]), younger than six months old (OR=3.1 [95% CI, 1.3 to 7.1]). The sensitivity of an abnormal urine analysis was 0.77 (95% CI, 0.66 to 0.88) and the specificity was 0.31 (95% CI, 0.2 to 0.42).

CONCLUSION:

An incremental increase in risk for UTI is associated with younger age (younger than six months), having a white blood cell count higher than 15,000/mm³, parental report of malodorous or foul smelling urine and the absence of an alternative source of fever. In the present patient population, obtaining a urine culture from children with at least one of these clinical predictors would have resulted in missing one UTI (2%), and 111 negative cultures (20%) would have been avoided.