'PURE' (Pediatric Urology Ramachandra Education)
Urinary infection/Vesico Ureteric Reflux
A child is considered to have urinary tract infection (UTI) when the urine of the child grows bacteria during a microbiological test (urine culture) and the amount is significantly high (more than one lakh per ml). During childhood 5% of girls and 2% of boys get UTI. In the new-born period more boys get UTI than girls. Among the girls half can get a second UTI within a year.
Why is UTI important in children?
The incidence of underlying kidney problem is far higher in children compared to adults. 30-50% of children with UTI can have a kidney problem. If left untreated, they can lead to multiple infection, kidney scarring and in the long term hypertension and renal failure.
How do we suspect urinary infection?
When the UTI involves bladder alone, one experiences frequent urination, lower tummy pain and burning sensation while passing urine. When the kidneys are also affected, high fever, vomiting, loin pain and feeling unwell, can be the features.
How is UTI diagnosed?
Initial urine tests with microscope can help to identify presence of UTI. However it is confirmed only after growing organisms in a large number in urine culture when tested in micro lab.
How is UTI managed?
After confirming the diagnosis, it is usually treated with a course of oral antibiotics. If kidney infection is suspected, the child may require hospitalization for IV fluids and antibiotics via IV route. Once UTI is treated, an ultrasound scan is requested to look for any underlying abnormalities.
What is Vesico Ureteric Reflux (VUR)?
In normal state, the urine travels in a one-way direction from kidneys to the bladder via the ureter. Once in bladder, the urine does not go back up either during storage or emptying. But in children with Vesico Ureteric Reflux (VUR), the urine goes upstream towards the kidneys. Because of this the kidneys are exposed to serious infection and scarring during any urinary infection.
How do we diagnose VUR?
A test called MCU is done to diagnose VUR. In this a special radio opaque dye is injected via a catheter into the bladder. X-rays are taken while the child passes urine. Normally urine should not go up towards kidneys. But in children with VUR it goes up.
Can it be familial?
There is a slightly higher chance in future kids to have VUR when there is a kid with this problem in the family.
What is the treatment for VUR?
When VUR is present the usual treatment is to put them on long term low dose antibiotics (sometimes up to 4-5 years). This prevents the kidney getting infected. Most of them do not require surgery.
Is it safe to give a child long term antibiotics? Will it reduce the immunity? What is the role of cranberry juice?
Long term antibiotics are only to protect kidneys. They are found to be safe and they do not cause reduction in immunity. Usually the doctor decides to stop it when the child attains bladder control (2-3 yr of age) or when the treatment is over. After this stage taking half a glass of cranberry juice daily is known to have a protective effect against urinary tract infection. This can be practiced till adolescence. Adequate intake of water/ citrus fruits/banana can help in avoiding constipation, an important cause of UTI.
When is operation required for VUR? What does it involve?
When a child gets recurrent urine infections despite being on antibiotics, or when the reflux is very high grade with kidney scarring, then surgery is recommended. In this the length of ureter inside the bladder is increased, thereby creating a one-way valve. This prevents urine going back upstream. It is done under general anesthesia and involves 5-7 days hospital stay. The success rate is above 95%.
Endoscopic treatment for VUR is possible in milder grades (grade 2-3) VUR. It involves injection of a paste like gel (Deflux) in the bladder where the ureter joins. This material prevents urine passage backwards. The advantage is it can be performed as a day care procedure (no need to stay in hospital). Disadvantage is cost (same as open surgery, as the medicine is expensive). In addition the success rate is around 70% and effect lasts for around an year after which a repeat injection may be required. However it is still a favorable option for milder grades of VUR as it does not involve open surgery.
What are the other problems that might require operation?
In boys, circumcision has shown to reduce UTI significantly. If there is a blockage to the urinary tract (posterior urethral valve), it will need correction. If there are congenital abnormalities of kidneys predisposing to UTI (duplication, diverticulum), they may need correction
What are the general measures one should take to prevent urine infections?
Dr. Ramesh Babu, MS, MCh, FRCS, Paediatric Surgeon, Paediatric Laparoscopic Surgeon and Paediatric Urologist Chennai. For further information contact: firstname.lastname@example.org; Mobile 9840359062