Urinary tract infections and congenital urological abnormalities in children

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Urinary tract infections and congenital
urological abnormalities in children

• Dr MJ Engelbrecht
• Dept Urology
• University of Pretoria

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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

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UTI in Children

• Diagnosis
• Urine bag
• Suprapubic aspiration
• Midstream urine specimen
• Interpretation
• Culture
• Midstream or urine bag collected specimen
• Single organism gt 100000 organisms/ml
• Suprapubic aspiration
• Any number of organism is significant

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UTI in children

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

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UTI in children

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

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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.

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Classification

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

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Prevalence

• 1-2 of children
• 20 30 of children with UTI
• Outosomal dominant genetic disorder
• 30 in siblings
• 50 in offsprings

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Complications

• Reflux nephropathy
• Hypertension
• Chronic renal failure
• 20 of pediatric renal transplant patients have
  reflux nephropathy

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Diagnosis

• VCUG
• gold standard
• Done after the UTI has been treated
• Advantages
• Grades reflux
• Excludes secondary
• causes of reflux
• Indirect nuclear
• cystography
• Ultrasound

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Diagnosis

• VCUG

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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

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Treatment

• Surgical
• Indications
• Failure of medical treatment to prevent UTIs
• 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 (gt90
  success)

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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

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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

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Diagnosis

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

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Diagnosis
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Treatment

• Conservative
• If no complications and gt 40 differential
  function
• Regular follow up with renal ultrasound
• Surgical
• Indications
• Decrease in differential function
• Complications
• UTI
• Renal failure
• Calculi

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Treatment

• Surgical
• Open surgical
• Pyeloplasty
• Endoscopic
• Endopyelotomy
• Balloon dilatation
• Laparoscopic
• Nephrectomy
• If non fuctioning kidney

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Posterior Urethral Valves

• Thin membrane obstructing the urethra distal to
  the verumontanum
• This cause proximal urethral dilatation, severe
  bladder trabeculation and bilateral hydronephrosis

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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

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In the acute setting

• Acute management
• Resuscitation
• Fluids
• Electrolytes
• Correct Acid base balance
• Treat UTI
• Urethral catheter
• Will relieve obstruction
• This will allow urosepsis and renal failure to
  resolve

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Diagnosis

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

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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