Urology: UTIs & Vulvovaginitis Flashcards
What is the most common causative organism for UTIs in children?
E. coli
What are some risk factors for UTIs in young people?
- Age <1 y/o
- Female (however in children <3 months UTIs are more common in boys)
- Caucasian
- Previous UTI
- Voiding dysfunction
- Vesicoureteral reflex (VUR)
- Sexual abuse: can cause urinary symptoms but infection is uncommon
- Spinal abnormalities
- Constipation
- Immunosuppression
However, in most cases there will be no associated risk factors.
Clinical features of UTIs in neonates & infants (<3 months)?
1) Non-specific:
- fever
- hypothermia
- jaundice
- vomiting
- diarrhoea
- lethargy
- failure to thrive
2) Respiratory distress or apnoea
3) Abdominal distension
Clinical features of UTIs in infants & toddlers (3 months - 2 years)?
1) Generalised symptoms:
- fever
- irritability
- poor appetite or vomiting
2) Strong smelling urine or diaper rash
Clinical features of UTIs in preschool & school aged children (2-12 years)?
1) LUTS:
- dysuria
- frequency
- urgency
- haematuria
2) Systemic symptoms:
- fever with chills (more common with pyelonephritis)
- abdo pain
In all children presenting with a fever, what is it is important to measure?
1) temp
2) HR
3) RR
4) CRT
Acute pyelonephritis/upper UTI should be suspected in children with what?
1) temperature of 38 degrees or higher and bacteriuria
2) temperature lower than 38 degrees with loin pain/tenderness and bacteriuria
What examinations should be done in suspected UTI in children?
- Throat & cervical nodes
- Abdomen: constipation, masses and tender or palpable kidney
- Back: look for stigmata of spina bifida or sacral agenesis
- Genitalia: look for phismosis, labial adhesions, vulvitis, or epdidymo-orchitis
Investigations in suspected UTI in children?
1) Urine dipstick
2) MSU sample (‘clean catch’ sample, avoiding contamination) –> if unexplained temperature of ≥ 38 degrees
When should a urine sample be sent for in children?
All infants with an unexplained temperature of 38 degrees or more should have their urine sent for microscopy and culture within 24 hours.
What 2 findings on a urine dipstick indicate a UTI in children?
Nitrites & leukocytes
What are next steps if leukocytes or nitrites are present on a urine dipstick?
Nitrites & leukocytes –> send MSU for culture, treated as UTI
Only nitrites –> treat as UTI
Only leukocytes –> don’t treat as UTI unless there is clinical evidence they have one
Neither –> UTI unlikely
Management of all infants <3 months with a suspected UTI (e.g. unexplain
Refer immediately to pediatrician
Management of children aged >3 months with lower UTI?
3 days oral Abx according to local guidelines (usually trimethoprim, nitrofurantoin, cefalexin or amoxicillin)
Management of children aged >3 months with upper UTI?
Consider admission for IV Abx.
If not admitted oral Abx such as cephalosporin or co-amoxiclav should be given for 7-10 days
What are the 4 typical Abx choices for UTIs?
1) Trimethoprim
2) Nitrofurantoin
3) Cefalexin
4) Amoxicillin
What imaging may be indicated in UTIs in children?
US
When is an US indicated for UTIs in children?
1) All children <6 months with their first UTI –> US within 6 weeks, or during infection if atypical/recurrent UTI
2) All children with recurrent UTIs –> within 6 weeks
3) All children with atypical UTIs –> during the illness
When should children with atypical UTIs have an abdo US?
During the illness
When should children with recurrent UTIs have an abdo US?
Within 6 weeks
What are some features of an atypical UTI?
- poor urine flow
- abdo or bladder mass
- raised creatinine
- sepsis
- failure to respond to treatment within 48h
- non E.coli organism
What is the definition of a ‘recurrent’ UTI?
1) Two or more episodes of upper UTI (pyelonephritis)
2) One episode of upper UTI and one episode of lower UTI
3) Three episodes of lower UTI
What information can an US give in UTIs?
- renal size
- can identify most congenital abnormalities
- renal calculi
- hydronephrosis: indicating the presence of obstruction or severe reflux
What does hydronephrosis indicate?
Presence of obstruction or severe reflux
What investigation can assess for damage from recurrent or atypical UTIs?
DMSA (Dimercaptosuccinic Acid) Scan
What does a DMSA scan involve?
Injecting a radioactive material (DMSA) and using a gamma camera to assess how well the material is taken up by the kidneys.
Where there are patches of kidney that have not taken up the material, this indicates scarring that may be the result of previous infection.
When is a DMSA scan done in UTIs?
4-6 months after infection
What is vesico-ureteric reflux (VUR)?
Where urine has a tendency to flow from the bladder back into the ureters.
This predisposes patients to developing upper UTIs and subsequent renal scarring.
What is the gold standard for diagnosing VUR?
Micturating cystourethrogram (MCUG).
Note - this imaging technique is invasive and requires catheterisation.
What imaging technique is the gold standard for detecting renal parenchyma defects and scarring?
DMSA Scintigraphy
Management of VUR?
Depends on severity:
- Avoid constipation
- Avoid an excessively full bladder
- Prophylactic antibiotics
- Surgical input from paediatric urology
What is vulvovaginitis?
Inflammation and irritation of the vulva and vagina.
This irritation is caused by sensitive and thin skin and mucosa around the vulva and vagina in young girls –> vagina more prone to colonisation and infection with bacteria spread from faeces.
Who does vulvovaginitis affect?
It is a common condition often affecting girls between the ages of 3 and 10 years.
What can vulvovaginitis be exacerbated by?
- wet nappies
- use of chemicals or soaps in cleanin the area
- tight clothing that traps moisture or sweat in the area
- poor toilet hygiene
- constipation
- threadworms
- pressure on the area e.g. horse riding
- heavily chlorinated pools
Why is vulvovaginitis much less common after puberty?
As oestrogen helps keep the skin and vaginal mucosa healthy and resistant to infection.
Presenting features of vulvovaginitis?
- soreness
- itching
- erythema around the labia
- vaginal discharge
- dysuria
- constipation
What may a urine dipstick show in vulvovaginitis?
A urine dipstick may show leukocytes but NO nitrites.
This will often result in misdiagnosis as a urinary tract infection.
Note - Often patients have already been treated for urinary tract infections and thrush, usually with little improvement in symptoms.
Management of vulvovaginitis?
Generally no medical treatment is required and management focuses on simple measures to improve symptoms:
- Avoid washing with soap and chemicals
- Avoid perfumed or antiseptic products
- Good toilet hygiene, wipe from front to back
- Keeping the area dry
- Emollients, such as sudacrem can sooth the area
- Loose cotton clothing
- Treating constipation and worms where applicable
- Avoiding activities that exacerbate the problem
What may be recommended in severe cases of vulvovaginitis?
Oestrogen cream
Define enuresis
Involuntary urination.
Nocturna: during the night (bed wetting)
Diurnal: during day
At what age do most children get control of daytime urination?
By 2 years
At what age do most children get control of nighttime urination?
By 3-4 years
Define primary nocturnal enuresis
Where the child has NEVER managed to be consistently dry at night.
What is the most common cause of primary nocturnal enuresis?
A variation on normal development, particularly if <5 y/o.
Often patients will have a family history of delayed dry nights. In this situation reassurance is important, and there is no need to jump to further investigations or management.
What are some other causes of primary nocturnal enuresis?
1) Overactive bladder
2) Fluid intake: prior to bedtime, particularly fizzy drinks, juice and caffeine, which can have a diuretic effect
3) Failure to wake: deep sleep and underdeveloped bladder signals
4) Psychological distress: low self esteem, too much pressure or stress at home or school
How can an overactive bladder result in 1ary nocturnal enuresis?
Frequent small volume urination prevents the development of bladder capacity.
What is the initial step in management of primary nocturnal enuresis?
To establish the underlying cause:
It can be helpful to keep a 2 week diary of toileting, fluid intake and bedwetting episodes.
History & exam for physical or psychological causes.
What does management of 1ary nocturnal enuresis involve?
1) Reassure parents of children under 5 years that it is likely to resolve without any treatment
2) Lifestyle changes:
- reduced fluid intake in the evenings
- pass urine before bed
-ensure easy access to a toilet
3) Encouragement and positive reinforcement. Avoid blame or shame. Punishment should very much be avoided.
4) Treat any underlying causes or exacerbating factors, such as constipation
5) Enuresis alarms
6) Pharmacological treatment
Define secondary nocturnal enuresis
Where a child begins wetting the bed when they have previously been dry for at least 6 months.
How long has a child been dry for previously in 2ary nocturnal enuresis?
At least 6 months
What are some causes of 2ary noctural enuresis?
1) UTI
2) Constipation
3) T2DM
4) New psychosocial problems (e.g. stress in family or school life)
5) Maltreatment
What should you always think about in secondary nocturnal enuresis?
Always think about abuse and safeguarding, particularly with deliberate bedwetting, punishment for bedwetting (despite parental education) or unexplained secondary nocturnal enuresis.
What are the 2 most common and easily treatable secondary causes of nocturnal diuresis?
UTIs & constipation
What is potential pharmacological option for noctural enuresis?
Desmopressin: particularly if short-term control is needed (e.g. for sleepovers) or an enuresis alarm has been ineffective/is not acceptable to the family.
What management step is generally first line for noctural enuresis?
Enuresis alarm
Is diurnal enuresis more common in males or females?
Females
What is urge incontinence?
an overactive bladder that gives little warning before emptying
What is stress incontinence?
leakage of urine during physical exertion, coughing or laughing.
What are the 2 main types of incontinence?
1) urge
2) stress
What are some causes of diurnal enuresis?
1) urge incontinence
2) stress incontinence
3) recurrent UTIs
4) psychosocial problems
5) constipation
What is an enuresis alarm?
A device that makes a noise at the first sign of bed wetting, waking the child and stopping them from urinating.
What is desmopressin?
An analogue of vasopressin (ADH).
It reduces the volume of urine produced by the kidneys –> taken at bedtime with the intention of reducing nocturnal enuresis.
What is oxybutinin?
An anticholinergic –> reduces the contractility of the bladder.
When may oxybutinin be indicated in enuresis?
When there is an overactive bladder causing urge incontinence.
What is imipramine?
TCA
What 3 medications may be indicated in enuresis?
1) Desmopressin
2) Oxybutinin (anticholinergic)
3) Imipramine (TCA)
Role of imipramine in enuresis?
Relaxes bladder and may lighten sleep.
When do the majority of children achieve day and night time continence?
By 3 or 4 years of age
Define enuresis
Involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract.
What are some possible underlying causes/triggers in nocturnal enuresis? (4)
1) constipation
2) diabetes mellitus
3) UTI if recent onset
4) emotional stress e.g. bullying, separation from mother, starting new school
Nocturnal enuresis can be defined as either 1ary or 2ary.
Define 2ary enuresis
The child has been dry for at least 6 months before
At what age is enuresis considered pathological?
≥5
Risk factors for enuresis?
- boys
- FH
- sleep apnoea (30%)
- obese children
General advice for enuresis?
- fluid intake
- toileting patterns: encourage to empty bladder regularly during the day and before sleep
- lifting and waking
- reward systems (e.g. Star charts)
What should reward systems be given for in enuresis?
NICE recommend these ‘should be given for agreed behaviour rather than dry nights’ e.g. using the toilet to pass urine before sleep
What is generally used 1st line for enuresis in children?
Enuresis alarm
These have sensor pads that sense wetness –> high success rate
What can be used for enuresis if an enuresis alarm has been ineffective/is not acceptable to the family or if short-term control is needed (e.g. for sleepovers)?
Desmopressin
What are 3 methods of collecting urnie sample from infant?
1) Bladder catheterisation (most common collection method for culture)
2) Bag collection
3) Suprapubic bladder aspiration (rarely used)
Give some risk factors for UTI in children
- Poor urine flow
- Previous UTIs
- Recurrent fever with no focus
- Antenatal renal abnormality
- History of VUR or renal disease
- Constipation
- Enlarged bladder/abdominal mass
- Spinal lesion
- Poor growth
- HTN
1st line abx in UTI in children?
Oral trimethoprim if child is quite well
Broad spectrum systemic abx in infants or
complicated/presumed upper tract involvement
What investigations are required for UTI in children <6 months?
Typical infection:
- USS
Atypical/recurrent infection:
- USS
- DMSA
- MCUG
What investigations are required for UTI in children 6m-3y?
Typical: none
Atypical/recurrent:
- USS
- DMSA
What investigations are required for UTI in children >3y?
Typical: none
Atypical/recurrent: USS (+DMSA if recurrent)
Define recurrent UTI in children
1) 2 or more UTI episodes, at least one episode with systemic signs of symptoms
or
2) 3 or more UTIs without systemic symptoms or signs
Define atypical UTI in children
1) Septicaemia/requires IV Abx
2) Non E.coli UTI
3) Poor urine flow
4) Abdo mass/bladder mass
5) Raised creatinine
6) Failure to respond to treatment with suitable Abx for 48h
Role of USS in UTI in paeds?
- Structural problems & obstructive abnormalities
- Acute pyelonephritis
- Discrepancy in renal size
Role of MSUG in UTI in paeds?
Looking for VUR
Mx of VUR?
Prophylactic antibiotics to prevent infection
Surgical correction for severe/problematic reflux
Role of DMSA in UTI in paeds?
Looking for renal scarring
