Dr MJ EngelbrechtDept Urology

University of Pretoria

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

Diagnosis Urine bag Suprapubic aspiration Midstream urine specimen

Interpretation Culture

Midstream or urine bag collected specimen Single organism > 100000 organisms/ml

Suprapubic aspiration Any number of organism is significant

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

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

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.

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

1-2 % of children 20 – 30 % of

children with UTI Outosomal

dominant genetic disorder 30% in siblings 50% in offsprings

Reflux nephropathy Hypertension Chronic renal failure

20% of pediatric renal transplant patients have reflux nephropathy

VCUG “gold” standard Done after the UTI has been treated Advantages

Grades reflux Excludes secondary

causes of reflux

Indirect nuclear cystography

Ultrasound

VCUG

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

Surgical Indications

Failure of medical treatment to prevent UTI’s 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 (>90%

success)

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

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

Ultasound First investigation Will show

hydronehrosis with normal ureter

IVP Show dilated renal

pelvis with normal ureter

MAG 3 renogram

Conservative If no complications and > 40% differential

function Regular follow up with renal ultrasound

Surgical Indications

Decrease in differential function Complications

UTI Renal failure Calculi

Surgical Open surgical

Pyeloplasty Endoscopic

Endopyelotomy Balloon dilatation

Laparoscopic Nephrectomy

If non fuctioning kidney

Thin membrane obstructing the urethra distal to the verumontanum

This cause proximal urethral dilatation, severe bladder trabeculation and bilateral hydronephrosis

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

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

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)

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