Urinary Tract Infections Epidemiology z More boys than girls get UTIs during the first year of life z Uncircumcised boys have as high as 10 times the risk of circumcised boys of having a UTI z By 1 year of age, 2.7% of boys and 0.7% of girls have had bacteriuria Classification Of Urinary Tract Infections z Initial (isolated) infections z Recurrent infections which classified as: z (1) unresolved bacteriuria during therapy z (2) bacterial persistence at an anatomic site z (3) reinfection Diagnosis z z z z Hx: Different symptoms in different age groups: fever, irritability, poor feeding, vomiting, and diarrhea in infants / LUTS, Hematuria in older kids. Other important p ppoints: Prenatal Hx includingg US /Voiding habits /constipation/sexual activity ROS/milestones /PMH/FH/Allergies Exam z General z Vitals z Abdominal z Genital z Back Investigations z z z z z UA, CS How to collect urine: bag, msu, cath, SP How to interpret p culture: count,, contaminants,, PT on CIC Radiology: US US, VCUG (conventional or nuclear), nuclear) Renography (MAG3 or DMSA) Others: voiding and stooling calendars, calendars uroflow with EMG recording, PVR, urodynamics, MRI Rx and prophylaxis z z z z z z Abx used: PO amoxil, PO: il keflex, k fl septra, trimethoprim, i h i nitrofurantoin, cipro IV amp, gent IV: Cystitis: 5 days of oral Abx Pyelonephritis: IV Abx till febrile for 24-48h then oral Rx for total of 10-14 days. Renal abscess: Same as pyelo unless no response to RX or big size abscess or obstructed kidney Chronic Pyelonephritis and Renal Scarring z z z z Renal scarring appears to be affected by at least five factors: intrarenal reflux, reflux urinary tract pressure, host immunity, age, and treatment Some of the scars take up to 2 years from the episode of pyelonephritis to evolve maximally Children with gross pyelonephritogenic nephropathy (reflux nephropathy) have at least a 10% to 20% risk of future hypertension Renal scarring and pregnancy VUR z z z VUR is found in up to 70% of infants who present with i h UTIs UTI Infants with antenatally detected reflux show a male preponderance in contrast to that diagnosed in the evaluation of UTIs later in life where females predominate VUR diagnosed g after investigating g g for antenatal hydro tends to be high grade and bilateral in boys, compared p with girls g Inheritance and Genetics z Reflux is the most common inherited anomaly of the genitourinary tract z There is high incidence of parent parent-to-child to child transmission (66%) z Up to 45% off siblings ibli have h been b notedd to have reflux in some studies where The large majority (75%) are asymptomatic Classification z Primary: deficiency of the longitudinal muscle of the intravesical ureter results in q valvular mechanism,, short an inadequate submucosal tunnel z Secondary: anatomical or functional obstruction Clinical Presentation z Antenatal hydro z UTI z Abdominal or flank pain z HTN z CRF z Impaired I i d somatic ti growth th Associated Anomalies and Conditions z Ureteropelvic Junction Obstruction z Ureteral Duplication z Bladder Diverticula z Multicystic dysplastic kidney z Megacystis-Megaureter Association Investigations and grading system z Natural History z Spontaneous resolution is related to several factors: z Increase in the length of the submucosal tunnel z Improved d bl bladder dd dynamics d i z Grade of reflux z Age at diagnosis Management z Medical: Abx prophylaxis, treat any secondary cause, trial of life z Surgical: sting, reimblantation z Complication of Sx and how to deal with it Indications for surgery 1. 2. 3. 4. 5. 6. Breakthrough UTIs despite prophylactic antibiotics N Noncompliance li with i h medical di l management Severe grades of reflux (grade IV or V), especially with pyelonephritic changes Failure of renal growth, new renal scars, or deterioration of renal function on serial ultrasounds or scans Reflux that persists in girls as full linear growth is approached at puberty Reflux associated with congenital abnormalities at the UVJ ((e.g., g , bladder diverticula))