UTI and Urology Flashcards
How do UTIs present different in kids and adults
- children are usually febrile
- kids often don’t have CVA tenderness
- or abdominal pain
- most common presentation is a fever w/o obvious source
When children, usually preschool age+, have ___ and _______, it is called uncomplicated UTI
dysuria and positive urine culture without fever
The majority of infections in neonates are descending infections, meaning:
they started with bacteremia, which seeded in their kidneys resulting in pyelonephritis
After the neonatal period, most infection are ___
ascending
with bacteria traveling up the urethra, and finally into the kidneys.
the most likely kids to get a febrile UTI is:
- neonatal uncircumcised boys (20.1%)
2. Caucasian girls less than 24 months old (16%)
Risk factors for UTI
- neonatal uncircumsized boy
- caucasian girl less than 24 months
- obstructive urological abnormalities (specifically vesicoureteral reflux (VUR), ureteropelvic junction (UPJ) obstruction, and posterior urethral valves)
- dysfunctional voiding (can also cause VUR)
What bacterias most commonly cause UTIs?
- E. coli (85%)- in peds
consider atypical bacterias in neonates, pts with UT anomalies and hx of recent Abx use
- Klebsiella
- Enterobacter
We worry about UTI in children because of the risk of ____
renal scarring if an upper tract infection remains undetected and untreated.
Renal scarring is most common in patients with:
- a hx of recurrent febrile UTI,
- those with treatment delays over 72H,
- dysfunctional elimination,
- obstructive uropathies,
- VUR.
renal scarring results in
- renal insufficency
- hypertension
- end-stage renal disease
___% of neonates with a UTI will test positive for urologic abnormalities, and ___% will have bacteremia or frank urosepsis with their UTI.
30-50%
20-30%
Of note in older children, parents will often report ___, although that is poorly correlated with UTI.
Additionally, sometimes infants have ____, and that has also been shown to be poorly correlated with actual UTI.
foul-smelling urine,
GI symptoms such as diarrhea
What is the typical UTI presentation of a neonate less than 3 months who is pre-term?
- Feeding problems
- apnea/bradycardia
- lethargy, tachypnea
*Note: Fever is often NOT present
What is the typical UTI presentation of a neonate less than 3 months who is full-term?
- Fever
- poor weight gain
- jaundice (conjugated bilirubin), vomiting
What is the typical UTI presentation of a infant less than 2 y/o?
- Suprapubic tenderness
- Fever over 102.2, without obvious source 48H or more
- Fever over 104
- Uncircumcised or with hx of prior UTI
What is the typical UTI presentation of a kid over 2y/o
- Abdominal pain
- 2◦ enuresis
- Back pain
- Dysuria +/- frequency
T or F?
Bubble baths are associated with the development of UTI?
Why?
False
7% of the population has an abnormality to their urinary tract lining which has a higher affinity for the hair cells on E. Coli. This is the population, who despite a normal tract anatomy otherwise, get recurrent UTI’s.
-Bubble bath can contribute to urethral irritation and dysuria. For patients with a history of a UTI, and therefore a possibility they are one of this 7%, the urethral irritation can be a setup for the development of a UTI. These are the only kids I recommend not use bubble bath.
T or F?
Cranberry juice can prevent a UTI?
Why?
False
Cranberry juice acidifies the urine, but has only been shown to be effective in women, not children.
T or F?
Inappropriate (back to front) wiping in females is associated with UTI?
Why?
How many infants spend over 5m in a poopy diaper at some point in their first 2 years of life? Yep, 100% and yet few get a UTI. Appropriate wiping instructions are best given to that small percentage of the population who has had a UTI.
T or F?
A UTI only exists if the urine culture is positive?
Why?
True
Because urine needs to stay in the bladder 3-4 hours to develop nitrite and other indicators of UTI, and young children urinate about every 2H, a negative urine dipstick is not reassuring. All children suspected of a UTI MUST have a culture to confirm. This is important as these children will have further testing if they have a culture-confirmed UTI.
T or F?
A negative urine dipstick rules out a pediatric UTI?
Because urine needs to stay in the bladder 3-4 hours to develop nitrite and other indicators of UTI, and young children urinate about every 2H, a negative urine dipstick is not reassuring. All children suspected of a UTI MUST have a culture to confirm. This is important as these children will have further testing if they have a culture-confirmed UTI.
Important history and exam clues to pediatric UTI
- Dysfunctional elimination
- Previous UTI or frequent undiagnosed febrile illnesses
- Family Hx: UTI, urologic abnormalities
- Elevated B/P and poor growth–>RI
- Enlarged bladder or kidney(s)–> obstructive uropathy
- Bladder/CVA tenderness
- External genitalia exam–> vulvovaginitis, pinworms, sexual abuse, trauma, STI
- Lower back exam for sacral dimples and tufts of hair–> spinal cord problem and possible neurogenic bladder
who is vuvlovaginitis most commonly seen in
preschool age girls who are toilet trained but have not yet developed good hygiene skills
First, the urine from a non-toilet-trained child must be collected via:
If children are toilet-trained, __ is acceptable
in-and-out urethral catheterization or suprapubic bladder aspiration
a clean catch urine
*Bag urine is never acceptable for culture, as it is often contaminated.
The ___ is the most reliable urinalysis
enhanced urinalysis
The microscopy is performed on unspun urine, looking for __ and __. This test is helpful in guiding your empiric management, pending the urine culture
- WBC’s (over 10wbc) and
2. bacteria (gram stain).
How reliable is the following on urine testing for a UTI?
- Dipstick: Nitrates + and LE +
- Dipstick: Nitrate OR LE +
- Dipstick: Nitrate AND LE -
- Standard urine micro:
- Enhanced urinalysis:
- Dipstick: Nitrates + and LE + === 50-90%
- Dipstick: Nitrate OR LE + === 35-65%
- Dipstick: Nitrate AND LE - ==== 2-6%
- Standard urine micro: == 65-80%
- Enhanced urinalysis: === over 90%
What defines a culture positive UTI with a clean catch urine sample?
over 100,000 cfu/ml, single pathogen
What defines a culture positive UTI with a catheterization urine sample?
- over 50,000 cfu/ml, single pathogen
- 10K-50K cfu/ml, single pathogen, indeterminate result- needs repeat
What defines a culture positive UTI with a suprapubic aspiration urine sample
any growth
What is the tx of an infant less than 2 months w/ a UTI?
- hospitalize as they need full septic workup due to their risk of bacteremia or urosepsis
- Additionally, the 2- antibiotic regimen that they are given contain an IV drug.
Who needs to be hospitalized for a UTI
- those under 2 months old
- toxic appearing on exam regardless of age
- immunocompromised
- significant vomiting or otherwise unstable to tolerate oral meds
- those with concerns about adequate follow-up and
- those who, after starting outpatient therapy, are not improving as expected.
*most treated as outpatient
How do you treat outpatient UTIs
*does not require a blood culture
- Empiric outpatient treatment of pediatric febrile UTI includes the use of 2nd or 3rd generation cephalosporins (such as cefprozil, cefdinir, cefixime, and IM ceftriaxone.)
- tx for 10 days for all ped febrile
- f/u daily for first 2-3 days, after which pt should be improving clinically and the culture will be ready for review–> may need to change Abx based on culture or hosp. admit if not improving
*Cefdinir and cefixime are both once-a-day oral medications which are very palatable.
If the patient is a chronic catheter-use patient (usually a patient with a neurogenic bladder), you need to consider ___ and add ___ to the Tx regimen for UTI
Enterococcus
Amoxicillin to the cephalosporin regimen.
If the patient’s symptoms are clinically resolved after treatment for UTI, is it necessary to do a “test of cure” urine c/s?
NO!!!
You will see this recommendation in your book, but this is no longer necessary.
What is the typical presentation of an uncomplicated UTI?
- over 2y/o
2. Lower tract sx (no fever)
what sx suggest upper tract involvment
- Fever,
- chills,
- flank pain
What sx suggest lower tract involement?
- dysuria,
- frequency,
- urgency,
- suprpubic pain
What is the evaluation and management of an uncomplicated UTI (lower tract involvement)
- The urinalysis and urine c/s work-up is still appropriate, although the urinalysis can be more helpful initially in these older children whose urine remains in their bladder long enough to accumulate nitrite and leucocytes.
- Initial antibiotic regimens remain the same for ages 2-13y, 13y+ can be treated with trimethoprim-sulfamethoxazole (Bactrim) or a cephalosporin.
- Duration of treatment can be 5-7d.
*.In sexually active girls, ask about their method of birth control as spermicide is a risk for UTI.
Differentials to consider in patients with dysuria, urgency or frequency would be:
- dysfunctional voiding (although these patients are at higher risk for UTI),
- vulvovaginitis (including that caused by pinworms),
- adenovirus cystitis (which is hemorrhagic),
- STI, and
- urethral strictures or foreign body.
Renal U/S is usually done soon after the UTI is confirmed with culture to rule out ___ or __
ureteral obstruction or renal abscess.
___ is the best imaging study to look for VUR, and should be done as soon as the patient is asymptomatic and it can be scheduled
VCUG
Should you use prophylatic Abx while awaiting the VCUG?
There has been some debate about prophylactic antibiotics while awaiting the VCUG. There is a current guideline to do so, and some urologists are in favor. Check with your practice’s urologist or do the VCUG before the Abx are completed.
-If prophylactic Abx are used, TMP-SMX or nitrofurantoin are drugs of choice, unless the child is less than 2m and then the choice is amoxicillin.
renal scintigraphy or DMSA scans, which are used to assess for:
- renal scarring or
2. can be used to identify acute pyelonephritis.
What children need a VCUG and Renal ULTZ with a febriel pediatric UTI
all children
Who needs a VCUG and Renal ULTZ with a non-febrile pediatric UTI
- less than 3y/o girls at 1st UTI
2. all girls w/ recurrent UTI not previously imaged
Who needs a VCUG and Renal ULTZ with a febrile and non-febrile UTI
- all males
- poor growth
- hx of urologic abnormalities
- FHx of renal disease
describe the defect of VUR (vesicoureteral reflux)
a shortened length of ureter within the bladder wall, which does not travel diagonally through the wall.
-a filling bladder would compress the wall and just push urine back up into the ureter.
In secondary VUR, there has been long-standing back pressure against the ureteral opening resulting in __
retrograde urine flow into the ureters.
How is the grade of reflux and degree of damage to the ureter and renal calyces determined in VUR
- it is graded on a 1-5 scale,
- Grade 1-2 are varying degrees of ureteral dilatation,
- grade 3-4 begins the blunting of the renal calyces and
- Grade 5 is a tortuous ureter with significant loss of renal calyx definition.
VUR is more common in who?
- Caucasian females
- less than 2 y/o
- in families with primary VUR
How is low grade (1-2) VUR managed?
- observed
- likely to outgrow by age 5: lengthening the portion of the ureter that travels through the bladder wall, providing better ability for the bladder wall to compress the ureteral opening as the bladder fills.
How is grade III VUR managed?
- gray area
- less than 2y/o and unilateral disease have more resolutin
How is grade IV-V VUR managed?
-surgery
IV: unilateral disease have more resolution
V: rarely resolves spontaneously
what are surgical options for VUR management?
- open surgical reimplantation with a 95% resolution rate, and
- endoscopic correction using Deflux, 75-85% success rate but recovery is much shorter
In the __ procedure, a small deposit of collagen material is placed near the ureteral opening to reposition it to impede urine retrograde flow.
Deflux
It is important that patients understand that the UTI’s will not stop with either VUR surgery. It is done to prevent the infection from reaching the kidneys. Preventing renal infections is important to prevent:
renal scarring and permanent renal damage with renal insufficiency.
What is common evaluation for low grade VUR
- observation with prompt evaluation during febrile illness and tx with Abx prn, although some may opt for Deflux.
- Chronic antibiotic prophylaxis is sometimes used although it has somewhat fallen out of favor.
Some fetuses are noted on prenatal ultz to have hydronephrosis. Often this is an isolated finding which resolves on a later prenatal ultz or has resolved by the time the infant is born. However, it is indicative of a possible ___
obstructive uropathy.
Most common obstructive uropathies are:
- VUR
- ureteropelvic junction (UPJ) obstruction and
- posterior urethral valves
the proximal portion of the urethra has an extra flap of tissue which impedes the flow of urine to some degree
posterior uretheral valves (type of obstructive uropathy)
Patients with obstructive uropathies typically present with:
- a febrile UTI, but can also present with
- hydronephrosis or
- much later in life with renal insufficiency due to renal damage from high urine back pressures.
when should prophylactic Abx be used when assess hydronephrosis or obstructive uropathies?
prophylactic antibiotics should be used in patients with severe hydronephrosis on their first postnatal ultz while awaiting further testing due to their high likelihood of having an obstructive uropathy
Amoxicllin 25mg/kg/day
Describe the postnatal evaluation of unilateral prenatal hydronephrosis that is mild-moderate (< or = 15 mm, 3rd trimester)
- Postnatal US (after 7 days from birth)
- Mild hydronephrosis → U/S at 3 months old
- Moderate or severe hydronephrosis → VCUG
- **Note if VCUG positive → prophylactic antibiotics and further evaluation
- **Note if VCUG negative and mild or moderate hydronephrosis → U/S at 3 months and stop antibiotics
- **Note if VCUG negative and severe hydronephrosis → functional renal scan diuretic renography to assess for obstruction
Describe the postnatal evaluation of unilateral prenatal hydronephrosis that is severe (> 15 mm, 3rd trimester)
- Start Prophylactic antibiotic: amoxicillin 25 mg/kg/d) at birth
- Postnatal US (after 48 hours)
- Mild hydronephrosis → VCUG
- Moderate or severe hydronephrosis→ VCUG OR Functional renal scan diuretic renography to assess for obstruction
- **Note if VCUG positive → prophylactic antibiotics and further evaluation
- **Note if VCUG negative and mild or moderate hydronephrosis → U/S at 3 months and stop antibiotics
- **Note if VCUG negative and severe hydronephrosis → functional renal scan diuretic renography to assess for obstruction
What is primary nocturnal enuresis?
if the child never achieved nighttime dryness
It is important for families to understand that nighttime bladder control for many children is not achieved until between ages ___. In fact, 16% of __y/o and 10% of __y/o have nocturnal enuresis, and then children begin to outgrow it with only 5% at age __y, 2-3% at __y and 1-2% persisting beyond __y
5-7y
5y/o
7y/o
10y
12-14y
15y.
what to educate families on for nocturnal enuresis
- nighttime bladder control is not achieved until between ages 5-7y/o and sometimes longer
- this is not something their child is choosing to do, or to lazy to address
There are several hypotheses around bedwetting including:
- a CNS maturational delay,
- functionally small bladder capacity, or
- a decreased response to vasopressin.
*It often runs in families, and is more common in males, so ask if the father of the child had nocturnal enuresis.
It is important to consider a ___ in nocturnal enuresis, especially __
sleep disorder
OSA
*OSA-affected children spend more time in REM sleep, which is when enuresis usually occurs
DDX for enuresis
- primary enuresis
- OSA
- DM/diabetes inspidius
- UTI
- pinworms
- sexual abuse
- dysfunctional voiding/elimination syndrome
- chronic renal insufficiency
Describe the Hx/PE for enuresis
- determing primary vs. secondary, nocturnal or diurnal (the latter more likely to be pathologic),
- exam for damp underwear,
- perineal irritation,
- constipation,
- growth/HTN,
- palpable bladder/urologic abnormalities, and
- a lower spine exam.
Describe the management of nocturnal enureiss
- UA
- assessing commitment of family/patient and clarification of goals with an understanding that treatment time is several months
- Options include reward charts for dry nights,
- bladder training to increase bladder capacity with target volume (in oz )of age +2 (checked weekly),
- fluid management so that 80% of fluids are ingested in a.m. and early afternoon and 20% (and no caffeine) after 5pm.
- The most effective management (67%) is a bed wetting alarm, with a cost of $50, and 12-16 week commitment.
- alarm clock to do timed voiding
- DDAVP tablets (vasopressin)– high relapse rate
describe a bed wetting alarm
The child wears a sensor on their underwear which is triggered at the initiation of urination, waking the child up. The child needs to finish urinating in the toilet, clean the sensor, change underwear/bedding if needed and return to sleep.
- Sensors, clean clothing and bedding are kept nearby with the understanding that the child develops the responsibility for taking care of this and returning to bed.
- Pt motivation is KEY!
describe how DDAVP tablets (vasopressins) can help with noctural enuresis management
- a significant relapse rate after discontinuation.
- Start at 0.2mg and titrate to 0.6mg at bedtime. Because of the relapse rate, most providers choose to use DDAVP for vacations or overnight camp when the child would benefit from being consistently dry without the stigma of machines or pull-up underwear.
- Because of titration, you need to start 2 weeks in advance.
Dysfunctional voiding is very prevalent in young children (__%) and should be part of your well child care screening of urination/stooling habits
15%
*Most parents don’t even recognize this behavior in their children unless specifically asked.
symptoms of dysfunctional voiding
- urgency
- urinary accidents
- holding maneuvers (potty dance, sitting and with the heel against the perineum to reduce the urge to urinate)
- These children will later develop hesitancy, dribbling and straining when they lose the typical neurologic and anatomical components of micturition.
The urgency from dysfunctional voiding from comes when? a
after hours of holding urine, followed by a desperate need to urinate even when they might have been asked to urinate minutes before
dysfunctional voiding is highly associated with:
- constipation (30-88%)
- development of UTI
- acquired VUR
- may have a hx of ADHD
when dysfunctional voiding is combined with constipation it is known as ___. Sx are:
dysfunctional elimination
the children start with constipation and lose the normal sensation of a full rectum due to the large stools which often are present in their rectum, and then lose the ability to tell the difference between the need to stool vs. the need to urinate.
what is the workup for dysfunctional elimination
- UA- looking for infection and proteinuria as evidence for renal damage from constant back pressure
- A first a.m. urine is always best for proteinuria, and if positive, follow with serum creatinine.
- A urine c/s is needed and a
- renal u/s may be necessary if obstruction is suspected.
- Screen for constipation and maybe ADHD.
tx of dysfunctional voiding
- behavior modification with timed voids q 2-3H,
- treatment of constipation,
- urinate prior to urgency,
- no straining,
- complete bladder emptying,
- avoid caffeine and bubble baths (due to their risk of UTI), and
- a reward chart for adherence.
- Urology referral may be needed.
___ is highly suspected when a testicle is not found in the scrotum and cannot be manipulated into the scrotum by the age of 6m.
Cryptorchidism
Cryptorchidism is more common on the __ side and the most common location of the undescended testicle is ___
left
just outside the external ring
PE finding of Cryptorchidism
even prior to palpation, is a poorly rugated scrotum.
___ is an abnormally located urethral opening, often in a ventral location.
Hypospadias
ddx of Cryptochidism
- If it is present, consider that the child may have ambiguous genitalia, with their “undescended testicles” actually being ovaries, and their penis- a clitoris.
- In a newborn consider that this may be congenital adrenal hyperplasia.
Cryptorchidism may be indicative of a genetic syndrome, so examine for ___
dysmorphisms
Management of cryptorchidism
- watchful waiting for the first 6 m of life, as some will descend spontaneously.
- After 6m, an ultz is often done to determine the location and,
- if necessary, a urologist will perform an orchiopexy to locate and affix the testicle in the scrotum.
Cryptochidism testicles are at higher risk for ___ and affixing them allows for:
CA
frequent patient self exams.
Retractile testes are a common finding and often placing the child in what position allows the testicle to relax into the scrotum
cross-legged and sitting
For a persistently retractile testis it is important to consider that the testicle may be _____ will result in a testicle that resides in the ___. *Therefore, retractile testes should be noted in the patient’s chronic problem list, and parents should be aware that the boy needs an exam at his pubertal growth spurt to assess testicular location.
on a short spermatic cord, that with increased stature
inguinal canal
___ are a common finding in infants, often noted by parents in the immediate days after birth.
Hydrocele(s)
describe the development of hydrocele(s)
- Their development happens during the 8th month of pregnancy when the testicle descends through the inguinal canal into the scrotum sometimes carrying a small connection of peritoneal lining, allowing peritoneal fluid to pass through the connection into the scrotum.
- After birth, vigorous crying increases intra-abdominal pressure, pushing the fluid into the scrotum.
describe the exam findings for a hydrocele
- a large, sometimes unilateral, swelling to the scrotum
- transillumination will reveal a uniform red glow of fluid- often w/ a dark area consistent w/ the shape and size of a testicle
It is possible for the communication to be large enough to also allow intestinal loop into the scrotum. This is an ___
inguinal hernia
work up of inguinal hernias
- can usually be palpated, or visualized during transillumination, as a tortuous mass in the scrotal sac.
- confirmed with ultz and are referred for urologic surgery
tx of hydroceles
- resolve spontaneously usually by 6 months of age
2. if not resolved by 1 y/o refer to urology
what is balanitis
when the glans penis becomes infected
*If the patient is uncircumcised, the glans and foreskin will be infected, and the diagnosis is balanoposthitis
Is balanoposthitis or balanitis more common
Balanoposthitis is significantly more common than balanitis.
sx of balanoposthitis or balanitis
- pain
- dysuria
- penile discharge
- swelling and erythema of glans penis
balanoposthitis or balanitis is associated with ___ and is common caused by what organisms?
- It is associated with poor hygiene or aggressive cleaning with soap.
- GAS, stap aureus, candida
what PE is important to do for balanoposthitis or balanitis
palpate the bladder for urinary retention
describe the treatmetn of balanitis/balanoposthitis
- topical bacitracin or Bactroban, or nystatin for Candida.
- Resolution of symptoms is rapid, usually 24H.
- If GAS is suspected, oral antibiotics are needed.
- Patient education consists of instruction on retracting the foreskin and cleaning the glans, but without forceful retraction or use of soap.
- Refer to urology if urinary retention is suspected or if this is a recurrent problem.
- Circumcision usually resolves recurrence.
What should you do if there is bilateral hydronephrosis on prenatal ultrasound?
should have postnatal U/S within first 48 hours
