urinary tract infection and its surgical causes

1. UTI IN CHILDREN – a surgeon’s view
Pranaya Panigrahi
MS, MCh,
Asst. Prof. IMS BHU, Varanasi

2. INTRODUCTION
 UTI is a common bacterial infection in infants and
children.
 The risk of having a UTI before the age of 14 yrs
-1- 3% in boys
- 3-10% in girls .
 In girls, the first UTI usually occurs by the age of 5
yr, with peaks during infancy and toilet training.
 In boys, most UTIs occur during the 1st yr of life; more
common in uncircumcised boys.
 During the 1st yr of life,
-M : F ratio is 2.8–5.4 : 1.
 Beyond 1–2 yr,
-M : F ratio of 1 : 10.

3. UTI
•Age
•Sex
•Risk factors
•Cystitis
•Pyelonephritis
•Asymptomatic Bacteuria
Antibiotics
1. OPD Basis
2. Indor Basis
Immediate intervention
specifically in obstructive
uropathy
Further
Evaluation
•High Risk
Group
•Recurrent UTI

4. CAUSE AND COURSE OF UTI

5. Common Definitions
• UTI-Infection of the urinary tract is identified by growth of a
significant number of organisms of a single species in the urine, in
the presence of symptoms.
• Recurrent UTI-Defined as the recurrence of symptoms with
significant bacteriuria in patients who have recovered clinically
following treatment.(≥ 2 febrile UTIs,1 febrile UTI + ≥ 1 cystitis,≥ 3
cystitis
• Pyuria-Urine containing white blood cells.
• Signinificant Pyuria-Defined as >10 leukocytes per mm3 in a fresh
uncentrifuged sample, or >5 leukocytes per high power field in a
centrifuged sample.

6. Common Definitions
• Bacteriuria-
1. Significant Bacteriuria-Colony count of >105/mL of
a single species in a midstream clean catch sample.
2. Asymptomatic Bacteriuria-Significant bacteriuria in
the absence of symptoms of urinary tract infection
(UTI).
• Simple UTI- UTI with low grade fever, dysuria,
frequency, and urgency; and absence of symptoms of
complicated UTI.
• Atypical/Complicated UTI-Presence of fever >39ºC,
systemic toxicity, persistent vomiting, dehydration,
renal angle tenderness and raised creatinine.

7. Gender and Age Relation
Major gender differences
Boys
•Disease of infancy (<1 year)
•peak incidence during neonatal age, then linear reduction
to 1 year of age
• Boys >girls during the first year of life
•Overall cumulative incidence during childhood about 3%

8. Gender and Age Relation
• Girls
– peak - at 6-12 months
– long tail of risk
– more common in girls > 6 months
– overall cumulative incidence during childhood is about
8% (about double in males)
Febrile UTIs (i.e. acute pyelonephritis) are the
most common serious bacterial infection of
childhood
About 5% of children presenting with fever will
have UTI

9. COLLECTION OF SPECIMEN FOR
CULTURE
A clean-catch midstream specimen is used to
minimize contamination by periurethral flora.
Contamination can be minimized by washing
the genitalia with soap and water.
Antiseptic washes and forced retraction of
the prepuce are not advised.
 In neonates and infants, urine sample could be
obtained by either suprapubic aspiration or
transurethral bladder catheterization.
Both techniques are safe and easy to perform.

10. The urine specimen should be promptly plated
within one hour of collection.
If delay is anticipated, the sample can be stored
in a refrigerator at 4ºC for up to 12-24 hours.
Cultures of specimens collected from urine
bags have high false positive rates, and are not
recommended.

11. A urine culture should be repeated in case
contamination is suspected, e.g., mixed growth
of two or more pathogens, or growth of
organisms that normally constitute the
periurethral flora (lacto- bacilli in healthy girls;
enterococci in infants and toddlers).
The culture should also be repeated in
situations where UTI is strongly suspected but
colony counts are equivocal.
The number of bacteria required for defining
UTI depends on the method of urine
collection.

13. Initial Evaluation
• On examination
– Degree of toxicity,
– Dehydration
– Ability to retain oral intake
– Blood pressure
– History regarding bowel and bladder habits
– Underlying functional or urological abnormality.
• Complete blood counts, serum creatinine and a
blood culture should be done in infants and
children with complicated UTI.
• Check for method of collection of urine specimen

14. Underlying Structural Abnormality
• Tight phimosis; vulval
synechiae
• Distended bladder
• Palpable, enlarged
kidneys
• Palpable fecal mass in the
colon

15. • Previous surgery
of the urinary
tract, anorectal
malformation,defo
rmed
spine,sacrum or
meningomyelocele

16. • Patulous anus;
neurological deficit in
lower limbs
• Urinary incontinence
• Abnormal
genitalia(Cloaca, UGS,
Female Epispdias or
Hypospadias
• Prolapsed ureterocele
or Ectopic Ureter

17. Features Suggestive of
Bowel Bladder Dysfunction
• Recurrent urinary tract infections
• Persistent high grade vesicoureteric reflux
• Constipation, impacted stools
• Maneuvers to postpone voiding (holding
maneuvers, e.g., Vincent curtsy, squatting)
• Voiding less than 3 or more than 8 times a
day
• Straining or poor urinary stream
• Thickened bladder wall >2 mm
• Post void residue >20 mL
• Spinning top configuration of bladder on
micturating cystourethrogram

18. Acute pyelonephritis/Upper urinary
tract infection
 Fever of 38 °C or higher with
Bacteriuria
 Fever lower than 38 °C with
loin pain/tenderness and
bacteriuria
Cystitis/lower urinary tract infection.
All other infants and children who
have bacteriuria but no systemic
symptoms or signs .
UTI

19. Antibiotic
•Oral/IV
•Simple/Atypical
•Duration
Imaging and
Treatment of
underlying cause
Prevention
Treatment Of UTI
( Only treat the
Symptomatic children
not pyuria )

20. Small infant <3 month
with UTI
Infants and children 3 months or older
with acute pyelonephritis/upper urinary
tract infection:
•Early referral to
secondary care
•IV antibiotics
•Aminoglycoside after
creatinine status
•Always search for
urinary tract anomalies
• Consider referral
• oral antibiotics for 7–10 days.
( low resistance pattern antibiotics eg
cephalosporin or co-amoxiclav.)
• If oral antibiotics cannot be used – IV,
cefotaxime or ceftriaxone for 2–4 days
followed by oral antibiotics for a total
duration of 10 days.

21. infants and children 3 months or older with cystitis/lower urinary tract infection
Alternative diagnosis
Antibiotics according to culture
Send urine for culture
Imaging
Reassessment if the infant or child is still unwell after 24–48 hours
Treat with oral antibiotics for 3 days (Trimethoprim,
nitrofurantoin, cephalosporin or amoxicillin)

22. Bacterial etiology
Typical
• Escherichia coli
• Klebsiella
• Proteus
• Staphylococcus
saprophyticus
Atypical
•Enterococci
•Pseudomonas
•Staphylococcus aureus
•S epidermidis
•Haemophilus influenzae
•Group B streptococci
Fungal infection should be suspected in preterm infant,
children with immunodeficiency and complicated uti on
prolong antibiotic therapy

23. Medication
Dose, mg/kg/day
Parenteral
• Ceftriaxone
75-100, in 1-2 divided doses IV
• Cefotaxime
100-150, in 2-3 divided doses IV
• Amikacin
10-15, single dose IV or IM
• Gentamicin
5-6, single dose IV or IM
• Coamoxiclav
30-35 of amoxicillin, in 2 divided doses IV

24. Medication
Dose, mg/kg/day
Oral
• Cefixime
8-10, in 2 divided doses
• Coamoxiclav
30-35 of amoxicillin, in 2 divided doses
• Ciprofloxacin
10-20, in 2 divided doses
• Ofloxacin
15-20, in 2 divided doses
• Cephalexin
50-70, in 2-3 divided doses

25. Guideline
AAP (2011) NICE (2007)
Action Statement 5:
Febrile infants with UTIs should undergo
renal and bladder ultrasonography.
In all children with severe or atypical
illness who do not respond to treatment
within 48 hours, early ultrasound scan is
recommended to identify structural
abnormalities of the urinary tract.
In children over 6 months of age with
simple first time UTI that responds to
treatment, routine ultrasound is not
recommended.

26. 6 month to 3yr<6 month 3yr and older
Respond well in 48 hrs (simple or first UTI)
USG within 6 wks

27. 6 month to 3yr<6 month 3yr and older
ATYPICAL UTI
USG in acute infection,
DMSA after 4to 6
month, VCUG after 6
wks,
USG in acute
infection, DMSA
after 6 month,
VCUG(optional)
USG in acute
infection

28. 6 month to 3yr<6 month 3yr and older
RECURRENT UTI
USG in acute infection,
DMSA after 6 month,
VCUG
USG within 6 wks
and DMSA after 6
month,
VCUG(optional)
USG within 6 wks
and DMSA after
6 month

29. • Childhood UTI indicate either an anatomic or
functional abnormality of the GUT.
• USG KUB with Post void in all.
• Xray Abd Pelvis- Mostly to look fecal loading,
calculus , spine and sacrum
• For atypical/recurrent UTI: USG first 2 days
• For good response: USG within 6 weeks

30. Minor OPD Procedure
• Phimosis-
Circumcision- 12 to 20
times decrease in risk
of UTI
• Cong. Prepucial
adhesion
• Meatal stenosis
• Acute balanoprosthitis
• Vulval Synechiae- Estrogen
cream
• Meatal Stenosis

31. Obstructive Uropathy
– PUV , VUJ obstruction,PUJ obstruction
– Duplex systems, ureteral anomalies
– AUV, diverticula, calculus
– Antibiotics
– Medical management
– Bladder drainage-Catheterization, Vesicostomy
– Temporary higher diversion
– Temporary upper tract drainage
1. - PCN
2. -DJ stenting
3. -ureterostomy
– Image
– Definitive management

33. Posterior Urethral valves
– Most common
Obstructive
uropathy
– Wide spectrum of
presentation
– MCU
– Catheterization
– Valve fulguration
– Diversion
– Fl up

34. • Anterior
Urethral Valve
– Similar
Presentaion as
puv
– Urethral
diverticulun
– MCU confirms
– Endoscopic
Incision
• Urethral
calculus

35. • Ureterocele-
– Pyelonephritis/
Rec
UTI/Obstructive
Uropathy
– Female
– Prolapsed
Ureterocele
– Associated
Duplex System
– Endoscopic
Incision/Deroofi
ng
– Reimplantation
– Partial
Nephrectomy

36. PUJ obstruction
• 10% cases present with
pyelonephritis
• 10% associated with VUR
• Mostly Detected
antenataly
• USG KUB
• DTPA Renal Scan
• MCU in Bilateral Cases
• Nephrostomy
• Pyeloplasty- Open ,
Laparoscopy, Robotic
assisted

37. PUJ obstruction
• 10% cases present with
pyelonephritis
• 10% associated with VUR
• Mostly Detected
antenataly
• USG KUB
• DTPA Renal Scan
• MCU in Bilateral Cases
• Nephrostomy
• Pyeloplasty- Open ,
Laparoscopy, Robotic
assisted

38. Urogenital sinus
• Rec UTI
• May be associated with
high grade VUR
• Small UB
• Only Evident by genitalia
examination
• Single opening in Vulva
• TUM

39. Vesicoureteral
reflux
Primary Vs. Secondary
Imaging – MCU,DMSA
Primary VUR –
-IRS grading
-UDS
-Medical mx
Antibiotics
Bladder drainage
-Surgi Mx
Grade
1 Into a non dilated ureter
2 Ureter, Pelvis, Calices, No dilatation
3 Mild to moderate dilatation of ureter, renal pelvis
and calyces with minimal blunting of fornices
4 Moderate ureteral tortuosity and dilatation of the
pelvis and calices
5 Gross diatation of the ureter pelvis and calices. Loss
of papillary impression and ureteral tortuosity

40. • VUR-VUR grade
– Management
Grades I and II
– Antibiotic prophylaxis if
breakthrough febrile
UTI.
Grades III to V
– Antibiotic prophylaxis
up to 5 yr of age.
Consider surgery if
breakthrough febrile
UTI.
– Beyond 5 yr:
Prophylaxis continued
if there is bowel
bladder dysfunction.
– Deflux
– Diversion
– UDS
– Reimplantation-Open,
Laparoscopy

41. • VUR-VUR grade
– Management
Grades I and II
– Antibiotic prophylaxis if
breakthrough febrile
UTI.
Grades III to V
– Antibiotic prophylaxis
up to 5 yr of age.
Consider surgery if
breakthrough febrile
UTI.
– Beyond 5 yr: Prophylaxis
continued if there is
bowel bladder
dysfunction.
– Deflux
– Diversion
– UDS
– Reimplantation-Open,
Laparoscopy

42. VUR grade Management
Grades I and
II Antibiotic prophylaxis until 1 yr old. Restart
antibiotic prophylaxis if breakthrough febrile UTI.
Grades III to
V Antibiotic prophylaxis up to 5 yr of age. Consider
surgery if breakthrough febrile UTI.
Beyond 5 yr: Prophylaxis continued if there is
bowel bladder dysfunction.

43. Antibiotic Prophylaxis
• UTI < 1 yr (awaiting
investigations )
• Frequent ‘febrile’ UTI (≥3
episode/Yr)
• Uri tract dilatation , on Ix
• VUR
• No role of cyclic therapy
• Asymptomatic
bacteriuria - no
treatment
Medication Dose,
mg/kg/d
ay
Remarks
Amoxycillin 10-15
Cephalexin 10-15
Drug of choice in first 3-6 mo
of life
Cotrimo
xazole
1-2*
Avoid in infants <3 mo,
G -6 –PD deficiency
Nitrofuran
toin
1-2
Vomiting and nausea; avoid
in infants <3 mo, G-6-PD
deficiency, renal insuff.,
resistant infections
Usually given as single bedtime dose;
*of trimethoprim.

44. Managing a Bowel Bladder
Dysfunction
• Managing the Constipation
Diet , laxative ,
Bowel training - re training
• Timed voiding , bladder diary
• Hygiene , ablution practices
• Involve the child , insight
• Psychological overlay, counseling

45. Prevention Of rec. UTI – renal scar
• General measures-
– Increase fluid intake
– Treat constipation , bowel habits
• Double voiding , timed voiding
• Circumcision , perineal hygiene
• Report with suspicious symptoms