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Recent Update on Pediatric

UTI
Stephen S. Yang, MD, PhD
Division of Urology,
Taipei Tzu Chi Hospital, New Taipei, Taiwan
Buddhist Tzu Chi University, Hualien, Taiwan
2017/08/17 10:15-30
Stephen S. Yang, MD, PhD
1. Chief Editor of Urological Science
2. Board member and Chairman of Standardization Committee of
International Children Continence Society
3. Vice President of Asian Association of UTI/STI
4. Secretary General and President Elect of Asia Pacific Association
of Pediatric Urology
5.Board member of Taiwan Continence Society
6. Board member of Taiwan Andrology Association
7. Executive board member of Go-South Urological Foundation

Disclosure: No conflict of Interest in this presentation


• Official publication of Taiwan
Urological Association
• Chief Editor: Stephen Shei-Dei Yang
• An Open Access Journal without
publication fee for the authors.
• Published quarterly by Elsevier
since 2010 (Bimonthly in 2018)
• Indexed in Chemical Abstracts
Service, PASCAL, Scopus, EMBase,
ScienceDirect and SIIC Data Bases.
• Included in ESCI
• Applying PubMed Central

http://www.urol-sci.com/
OUTLINE:
•Bladder Bowel Dysfunction
•Vesicoureteral Reflux
•Prophylactic antibiotics
1. UAA/AAUS-UTI/GTI/STI Guidelines
(to be published in Int J Urol)
2. ICCS position paper on BBD and UTI
(To be published in Ped Nephrol)
3. Personal Experience
Diagnosis and Management of Bladder
Bowel Dysfunction in Children with
Urinary Tract Infections: A Position
Document from the International
Children’s Continence Society (ICCS)
Stephen S. Yang, Michael Chua, Anne Wright, Stuart Bauer, Per Brandström, Piet Hoebeke,
Elizabeth. Jackson, Mario De Gennaro, Eliane Fonseca, Anka J Nieuwhof-Leppink, Paul Austin, Søren Rittig
Division of Urology, Taipei Tzu Chi Hospital and the other 11 centers

Accepted on August 9, 2017.


Conclusion:
When treating children with febrile UTI, BBD
should be assessed and treated aggressively!
Bladder and bowel dysfunction (BBD)=
Lower Urinary Tract Dysfunction (LUTD)
+/- bowel dysfunction

N Enuresis UTIs VU Reflux


Incontinence

Renal HT
Scarring ESRD
RISK FACTORS AND POSSIBLE TREATMENTS OF UTI

circumcision
RISK FACTORS AND POSSIBLE TREATMENTS OF UTI

circumcision
RISK FACTORS AND POSSIBLE TREATMENTS OF UTI

circumcision
RISK FACTORS AND POSSIBLE TREATMENTS OF UTI

circumcision
RISK FACTORS AND POSSIBLE TREATMENTS OF UTI

circumcision
Normal LUT Function in Children
* Voiding frequency 4 to 6 times/day. (Lee 2014)
* At optimal bladder volume (<115% EBC),
uroflowmetry is bell-shaped with good Qmax and
minimal PVR (Yang 2008, 2013, 2014, Chang 2009, Austin 2014)
* EBC= (age in years *+1) *30ml

Age Qmax (ml/s) PVR (ml) PVR (% BV)


4-6 years > 11.5 <20 <10
7-12 years > 15.0 <10 <6
Elevated PVR and Recurrent f-UTI in Children

High PVR by ml High PVR by % BV

Chang SJ, Tsai LP, Hsu CK, Yang SS. Pediatr Nephrol. 2015
Jul;30(7):1131-7. doi: 10.1007/s00467-014-3009-y. Epub 2015 Feb 12.
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(UFM + PVR) *2 in 100 children with PNE

• *: At least one elevated PVR


• **: Nocturnal urine > 130%BC
Chang SJ, Yang SS. Int Brazil J Urol 20170811 under revision
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(UFM + PVR) *2 in 100 children with PNE

• *: At least one elevated PVR


• **: Nocturnal urine > 130%BC

Chang SJ, Yang SS. Int Brazil J Urol 20170811 under revision
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Normal LUT Function in Children

Age Qmax PVR PVR


(ml/s) (ml) (% BV)
4-6 > 11.5 <20 <10
years
7-12 > 15.0 <10 <6
years
Uroflowmetry Patterns
Typical Flow P, I, S, T
Patterns (ICCS)

Normal Bell

Chang SJ, Yang


SS: J Ped Urol.
2008;4:422-7
2017/8/17

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J Urol 2008;180:2177-2182

Expected BC=
(age in years +1)
*30ml
The ROC curve for the
nonbell-shaped curves vs.
bell shaped curve in all 355
voidings.
J Urol 2008;180:2177-2182
Optimal Bladder Capacity
• Upper range: 115% EBC. Adults= 575ml?
• EBC=(age in years *30)+30ml
• Lower range:(Age in years*5)+50ml. Adult= 150ml

• Above upper range: Qmax decreased, PVR elevated,


and Flow pattern changed.
• Below lower range: Qmax is low, flow patterns may
change with bladder volume.
Yang SS & Chang SJ. J Urol. 2008;180:2177
Chang SJ, Yang SS et al: LUTS 2016 Mar 16. doi: 10.1111/luts.12128
Functional Constipation in infants/ Children
Prevalence: around 20%
Rome IV: ≧2 criteria in at least 25% of
defecations for 1 month: (Hyams 2016)
a. Straining
b. Lumpy or hard stools
c. Sensation of incomplete evacuation
d. Presence of anorectal obstruction/
blockage
e. Manual maneuvers to facilitate
defecations
f. <3 defecations per week
Functional Constipation in infants/ Children
Rome IV: ≧2 criteria in at least 25%
of defecations for 1 month: (Hyams
2016)
a. Straining
b. Lumpy or hard stools
c. Sensation of incomplete
evacuation
d. Presence of anorectal
obstruction/ blockage
e. Manual maneuvers to facilitate
defecations
f. <3 defecations per week
Treatment Strategy for BBD and UTI

Yang SS, et al. Ped


Nephrol 2017

23
Treatment Strategy for BBD and UTI

Yang SS, et al.


Ped Nephrol 2017
24
Treatment Strategy for BBD and UTI

Yang SS, et al. Ped


Nephrol 2017

25
Treatment of Constipation: 4-Step Approach
• Education and demystification regarding bowel
physiology and dysfunction
• Fecal disimpaction (use enema or suppository)
• Prevention of fecal re-accumulation (maintenance
therapy)
• Behavioral therapy with follow-up (Mugie 2011, Burgers
2013).
• Polyethyline glycol 3350 (Miralax). (Yang in Taiwan:
MgO 250mg 1-2 tab tid, Sennoside)

Yang SS, et al. Ped Nephrol 2017


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Treatment of Constipation: 4-Step Approach
• Education and demystification regarding bowel
physiology and dysfunction
• Fecal disimpaction (use enema or suppository)
• Prevention of fecal re-accumulation (maintenance
therapy)
• Behavioral therapy with follow-up (Mugie 2011, Burgers
2013).
• Polyethyline glycol 3350 (Miralax). (Yang in Taiwan:
MgO 250mg 1-2 tab tid, Sennoside)

Yang SS, et al. Ped Nephrol 2017


27
Treatment of Constipation: 4-Step Approach
• Education and demystification regarding bowel
physiology and dysfunction
• Fecal disimpaction (use enema or suppository)
• Prevention of fecal re-accumulation (maintenance
therapy)
• Behavioral therapy with follow-up (Mugie 2011, Burgers
2013).
• Polyethyline glycol 3350 (Miralax). (Yang in Taiwan:
MgO 250mg 1-2 tab tid, Sennoside)

Yang SS, et al. Ped Nephrol 2017


28
Treatment of Constipation: 4-Step Approach
• Education and demystification regarding bowel
physiology and dysfunction
• Fecal disimpaction (use enema or suppository)
• Prevention of fecal re-accumulation (maintenance
therapy)
• Behavioral therapy with follow-up (Mugie 2011, Burgers
2013).
• Polyethyline glycol 3350 (Miralax). (Yang in Taiwan:
MgO 250mg 1-2 tab tid, Sennoside)

Yang SS, et al. Ped Nephrol 2017


29
Treatment for constipation
• Maintenance therapy in treating constipation may be
required for months to years afterwards. (Mugie 2011)
• Dietary fiber and probiotics are helpful in managing
functional constipation but their role and efficacy
remain unclear. (Burger 2013, 2016)
• Refer to experts in refractory cases lasting more than 6
months, despite conventional therapy (Burgers 2013).

Yang SS, et al. Ped Nephrol 2017


30
Treatment for constipation
• Maintenance therapy in treating constipation may be
required for months to years afterwards. (Mugie 2011)
• Dietary fiber and probiotics are helpful in managing
functional constipation but their role and efficacy
remain unclear. (Burger 2013, 2016)
• Refer to experts in refractory cases lasting more than 6
months, despite conventional therapy (Burgers 2013).

Yang SS, et al. Ped Nephrol 2017


31
Treatment for constipation
• Maintenance therapy in treating constipation may be
required for months to years afterwards. (Mugie 2011)
• Dietary fiber and probiotics are helpful in managing
functional constipation but their role and efficacy
remain unclear. (Burger 2013, 2016)
• Refer to experts in refractory cases lasting more than 6
months, despite conventional therapy (Burgers 2013).

Yang SS, et al. Ped Nephrol 2017


32
OUTLINE
• Bladder Bowel
Dysfunction
• Vesicoureteral Reflux
• Prophylactic antibiotics
OUTLINE
• Bladder Bowel
Dysfunction
• Vesicoureteral Reflux
• Prophylactic antibiotics
Tsai YC, Yang SS* : Mini-laparoscopic Nerve Sparing
Extravesical Ureteral Reimplantation for Primary
Vesicoureteral Reflux: A Preliminary Report. J
LAPAROENDOSC ADV S. 2008:18:767-770.
Why VUR Occurs?
Urethral lumen is
much larger than
ureter.
Why urinary flow
chooses small
caliber?
Why VUR Occurs?
Detrusor Pressure >
Ureteral Resistance
* High Detrusor Pressure: Infant
bladder, Detrusor Overactivity
Neurogenic Bladder, and High
Bladder Outlet Resistance?
* Low Ureteral Resistance:
Parureteral diverticulum, Short
Subureteral tunnel?
Why VUR Occurs?
Detrusor Pressure >
Ureteral Resistance
* High Detrusor Pressure: Infant
bladder, Detrusor Overactivity
Neurogenic Bladder, and High
Bladder Outlet Resistance?
* Low Ureteral Resistance:
Parureteral diverticulum, Short
Subureteral tunnel?
Why VUR Occurs?
High bladder outlet resistance, High Detrusor Pressure

EMG

Pves

Pabd

Pdet

Qura
VUR and Dysfunctional Voiding
1 3

2 4
VUR and Dysfunctional Voiding
VUR and Dysfunctional Voiding
VUR and Dysfunctional Voiding
VUR and Dysfunctional Voiding
Detrusor BoNT-A Down-graded VUR

High grade VUR improved


in 11/15 (73%)
children with MMC + NDO

10/15 (65%) fecal


incontinence improved

Kajbafzadeh AM, et al:


UROLOGY 2006; 68:
1091-1097.
VesicoUreteral Reflux VUR (Han CH)
* Surgical intervention should be used to treat VUR
in the setting of recurrent febrile UTI because it has
been shown to decrease the incidence of recurrent
pyelonephritis (GoR A).
* Bladder dysfunction increases the risk of UTI and
can lead to significant delay in resolution of VUR.
(GoR B).
Diagnose and treat BBD
before surgical intervention of VUR.
OUTLINE
• Bladder Bowel
Dysfunction
• Vesicoureteral Reflux
• Prophylactic antibiotics
CAP for Pediatric UTI

Hewitt IK, et al:


Pediatrics
2017;139 (5):
e20163145
CAP for Pediatric UTI

No benefits of CAP in
the prevention of renal
scarring in all cases
Pediatrics 2017;139
(5): e20163145
CAP for Pediatric UTI

No benefits of CAP in the


prevention of renal
scarring in cases with VUR
Pediatrics 2017;139 (5): e20163145
Continuous Antimicrobial Prophylaxis (Han CH)

1. The potential benefit of preventing


recurrent UTI by antimicrobial prophylaxis
should be weighed against the risk of
antimicrobial resistance with future infections.
(GoR B)
2. Antimicrobial prophylaxis to prevent
recurrent UTI MAY be considered in infants and
children with or without vesicoureteral reflux
(VUR) after a first UTI. (GoR B)
Plan for Pediatric UTI Hewitt IK

Asia Yes No, Yes, No


Febrile UTI
Take Home Message
• Diagnose and Treat Bladder Bowel
Dysfunction in all cases of UTI, before
surgery of VUR.
• Prophylactic antibiotics in highly selective
case of pediatric UTI to avoid multiple drug
resistance super bug.
Fellowship in Urodynamics & Ped Urol
Taiwan:
-嘉義長庚: 林威宇
-奇美醫院: 蘇家震、李高漢、謝坤霖
-馬偕醫院: 魏晉弘、傅玉瑋

International:
-Vietnam: Yuan Q, Viet D.
-Philippines: Flores F, Chua
M
Indonesia: Sibarani J,
Yacobda S.

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