Urinary tract infectio

Vesiculoureteral reflu

Urinary tract infection

Bacteria infection most common

Viral infection
Fungal infections -- rare and occur most
commonly
in immunocompromised individuals (HIV/AID
S,chemotherapy recipients)

Prevalence

1-3 % in female , 1% in male

Usually occurs; Female 5 yr , Male 1 yr
During 1st year; Female : Male = 1 : 2.8-5.4
During 1-2 year; Female : Male = 10 : 1

Predisposing Risk Factors

Gender
as or more common in boys as neonates
after neonatal period, incidence higher in females
Urinary obstruction
Posterior urethral valve and urethral stricture
Meatal stenosis
Bladder neck obstruction
Previous UTIs

Urinary instrumentation (e.g., catheterization)

Immunocompromise
Diabetes mellitus
Bladder calculi

Urinary tract infection

Uncomplicated UTI

Healthy
Normal anatomic and physiologic status

Complicated UTI

Abnormal anatomic and physiologic status

Pregnancy
Diabetes mellitus
Immunocompromised
Indwelling catheter
Presence of symptoms 7 days

Urinary Tract Infection

Upper urinary tract infection

Pyelonephritis (acute ,chronic)

Intrarenal abscess
Perinephric abscess

Lower urinary tract infection

Cystitis
Urethritis

LOWER URINARY TRACT

INFECTION

Cystitis
Urethritis

Cystitis

An inflammation of the bladder

Common etiologic agent

E. coli -- most common

Klebsiella spp.
Group B Streptococcus
Proteus
Staphylococcus epidermis
Pseudomonas
H. influenza
Enterococcus
Staphylococcus saprophyticus

Clinical feature

Dysuria
Urgency
Frequency
Lower abdominal pain : suprapubic region
Symptoms in children

Weakness
Irritability
Reduced appetite
Vomiting
Pain when urinating

Urethritis
An inflammation of the urethra
Gonococcal urethritis
Neisseria gonorrheae
S/S :

Male purulent discharge,dysuria

Female -- often asymptomatic

Nongonococcal urethritis
Variety of bacteria : Chlamydia trachomatis, Mycoplasma,
Ureaplasma

Adenovirus, Trichomonas vaginalis, Herpes simplex virus

S/S :

Male cloudy or watery discharge, dysuria, swollen or tender testicles

Female often asymptomatic

UPPER URINARY TRACT

INFECTION

Pyelonephritis (acute ,chronic)

Intrarenal abscess
Perinephric abscess

Acute Pyelonephritis

Chronic pyelonephritis

(vesico-ureteral reflux: VUR )

Reflux Nephropathy

Type

Uncomplicated pyelonephritis: Upper urinary tract

infection that presents with fever (>38C) (though may
be absent early on), chills, flank pain, costovertebral
angle tenderness, and nausea/vomiting,+/- signs or sy
mptoms of acute cystitis. Pathogens are often more resi
stant to typical antibiotics than those leading to cystitis.
Complicated pyelonephritis: Progression of upper
urinary tract infection to emphysematous pyelonephritis,
renal corticomedullary abscess, perinephric abscess, or
papillary necrosis.

Renal and Perirenal Abscesses

renal abscess

carbuncle

(A collection of purulent material confined to the
renal parenchyma)
80
S. Aureus Streptococci

Renal and Perirenal Abscesses

( perinephric abscess)

Etiology
In neonates, infection is assumed to
be hematogenous in origin rather than
ascending. This feature may explain
the nonspecific symptoms associated
with UTI in these patients.

UTIs are generally ascending in origin and

caused by
perineal contaminants, usually bowel flora.

http://emedicine.medscape.com/article/968028-overview#aw2aab6b2b2aa

Etiology

Bacterial pathogens are the most common cause of pyelonephritis.

Bacterial sources of pyelonephritis include the following:
Escherichia coli -This is by far the most common organism,
causing more than 90% of all cases of acute pyelonephritis
Extended-spectrum beta-lactamaseproducingE coliis becoming
more frequent[4]
Klebsiella oxytocaand species
Proteusspecies
Enterococcus faecalisand species
Gram-positive organisms, including staphylococcal species and
group B Streptococcus-These are rare causes of acute
pyelonephritis

Pathophysiology

The most important virulence factors, in patients whose

urinary tracts are normal
govern adherence or attachment to host mucosal cells.
Adhesins, molecules mediating attachment, are on
the surfaces of bacteria or bacterial appendages.
Three major adhesins associated with strains of E coli
causing UTI are PAP, AFA, and SFA.
Host defenses against the development of UTI relate
primarily to anatomic and physiologic considerations.
The ability to empty the bladder of urine regularly and
completely is the most important host defense
mechanism against infection.

Pathophysiology

ttp://what-when-how.com/acp-medicine/urinary-tract-infections-part-1/

Presenting symptoms and signs

in infants and children with UTI
Age group

Symptoms and signs

Most common ------------------>
Leastcommon

Infants younger than 3months

Fever

Poor feeding

Abdominal

, ,

Vomiting

Failure to

pain

Lethargy

thrive

Jaundice

Irritability

Haematuria
Offensive
urine

Infants and

Preverbal

Fever

Abdominal

Lethargy

children, 3months

pain

Irritability

or older

Loin

Hematuria

NICEguidelines [CG54] and https://www.urology.wisc.edu/system/assets/623/module_7_pediatric_uti.pdf?1268758371

Presenting symptoms and signs

in infants and children with UTI
bacteriuria and
fever of 38C or
higher

fever lower than 38C

with loin pain/tenderness
and bacteriuria

acute pyelonephritis/
upper urinary tract
infection.
bacteriuria but no systemic symptoms or signs
should be considered to have cystitis/lower UTI
NICEguidelines [CG54] and https://www.urology.wisc.edu/system/assets/623/module_7_pediatric_uti.pdf?1268758371

Physical Examination

General appearance
Most infants and children are uncomfortable and appear ill.
Vital signs
Fever may be present, with BT more than 38C, and often
more than 39C.
Tachycardia may be present, secondary to fever and pain.
Blood pressure is usually normal. Hypertension should
raise concern for clinically significant obstruction or renal
parenchymal disease.
Hypotension may occur if sepsis and shock are present.

Physical Examination

Abdominal findings
Abdominal pain may be present.
A mass may indicate obstruction,
hydronephrosis, or another anatomic
abnormality.
Suprapubic pain may be present.
A palpable bladder indicates obstruction or
functional difficulty in starting or completing
voiding.
Adolescent girls may have right upper quadrant
pain

Physical Examination

Back findings
Tenderness in the costovertebral angle (CVA), or flank
likely to be present in older children and adolescents.
Sacral dimple or birthmarks overlying the spine may be
associated with an underlying anomaly of the spinal
cord. Vertebral abnormalities may be evident.
Genitourinary findings
Assess for irritation, pinworms, vaginitis, trauma, or
signs of sexual abuse.
A bulging hymen suggests an imperforate hymen and
urethral obstruction.
Neurologic findings

4-5
,
, ,

,
, ,

,

(encopresis)

costovertebral angle
lipoma, hair patch, dimple, sinus tract lumbosacral

phimosis, vaginitis, labial adhesion

neurogenic bladder
rectal
sphincter

2.1 (urinalysis)
(dipstick) microscopic exam

2.1.1 leukocyte esterase ( pyuria

detect esterases neutrophils) nitrite (
nitrate
nitrite) dipstick
2.1.2
WBC 5 /HPF(pyuria)
2.1.3 (
Grams stain )
1 /oil power field

2.2
(gold standard)

a)
(ill appearance)

urinalysis
b) urinalysis
2.16, 7
c) urinalysis

a) Suprapubic aspiration
2
phimosis labial adhesion
urethral catheterization
b) Urethral catheterization 3

c) Clean-catch, midstream void
3
(strap-on bag)
(urinalysis)

suprapubic
aspiration

( colony/.)
catheterized 103 colony/.
clean-voided (midstream) 105
colony/.

dehydration

empirical antibiotics ( sensitivity)

Ampicillin 50-100 ././

Gentamicin 3-5 ././
3rd generation
Cephalosporins

aminoglycosides Gentamicin 5 ././
(
) 3rd
generation Cephalosporins Cefotaxime 100-200
././, Ceftriaxone 50-100 ././

48-72 .

10-14
acute pyelonephritis
circumcision phimosis

()

, ,
nitrite test
screening test

(> 3 // )
prophylaxis Cotrimoxazole 1-2 ./
./ trimethoprim Nitrofurantion 1-2
././ 6-12


,
,

VESICULOURETERAL
REFLUX (VUR)

Vesiculoureteral reflux

Retrograde flow of urine from the bladder to

the ureter and kidney
Flap valve mechanism & Ureteral attachment
to the bladder normally is oblique prevent
reflux

Epidemiology

10% of children

VUR is the most common urologic anomaly in

children

The incidence decreases as age increases (uncommon after

the age of 5 years
Boys tend to present at a younger age
Among older children, girls are affected approximately four
times more frequently than boys
29% of males and 14% of females with a UTI go on to have
a diagnosis of VUR
20% to 40% of children & 70% of infant with UTIs have VUR

Classification
1.
2.

Primary VUR
Secondary VUR

Primary VUR
Most common type
Congenital anomalies
Defect in development of the valve mechanism
of the vesicoureteral junction (shortening of
intravesical ureter or Malformation)
Spontaneous
Shortening
of resolution can occur with growth
Incompetence
the
Urine
of the valvular
intravesical
Reflux
mechanism
ureter

Primary VUR

Secondary VUR
Associated with
Increased intravesical pressure

Lower urinary tract obstruction

Neurogenic bladder
Voiding dysfunction

Inflammation process
Surgery procedure
Management of secondary VUR is focused on
treating the primary abnormality
Increased
Urine
Fail to close
intravesical
Reflux
UVJ
pressure

Reflux
Pathophysiology Ascending
Infection
Recurrent
pyelonephritis
Reflux nephropathy
(Scarring)

Extensive renal scar

Ischemia & Inflammation

ReninImpaired
mediated
Renal function
hypertension

ESRD

Grading of VUR

International Reflux Committee

Clinical manifestation
Symptoms

Fever
Irritability
Poor weight gain (FTT)
Smelly urine
Abdominal Pain
Dysuria, frequency, urgency
Haematuria
Enuresis and dysfunctional
voiding
Constipation, thread worm
infection, sore vulva

Non-specific
symptoms

Diarrhea
Lack of appetite
Irritability
Nausia and Vomitting

Untreated VUR

Bed-wetting
High blood pressure
Proteinuria
Kidney failure

Investigation
1.
2.
3.
4.

Ultrasonography
Voiding cystourethrography (VCUG)
Radionuclide cystography (RNC)
DMSA scan

Ultrasonography

Non invasive method

Cannot rule out reflux

40% of reflux have abnormality on u/s

Assess for

renal size
upper tract abnormalities, such as hydronephrosis and
ureteral dilatation
obvious scarring
ureteral ectopia or bladder abnormalities, such as
ureterocele
bladder wall thickening

Ultrasonography

Voiding cystourethrography
(VCUG)

Invasive method
Gold standard (Detect VUR and Grading) *

Contrast Filling and X-ray examination during

voiding
Reflux occurring during filling is termed lowpressure reflux or passive refluxed
Reflux occurring during voiding is termed highpressure reflux or active reflux
presence and extent of reflux delineates the
bladder outline, bladder neck, and ureteral and
urethral anatomy and bladder capacity

Voiding cystourethrography
(VCUG)

Radionuclide cystography
(RNC)

Nuclear scan of bladder

More sensitivity ,but Less capacity of grading
than VCUG
More expensive than VCUG
Use to Follow up
radioactive fluid are injected into the bladder
throughcatheter

Radionuclide cystography
(RNC)

DMSA scan

Morphology and structure of kidney

IV DMSA uptake by the kidney measure in
2-4 hr.
Areas of decreased uptake represent
pyelonephritis or scarring.
expensive, invasive and expose radiation
Identify >70% of VUR grade III or higher
Recommended when a renal ultrasound is abnormal,
greater concern for scarring (grade III-V VUR),
elevated serum creatinine

DMSA scan

Natural History

Persistent reflux in
age 1-5 yr.

Natural History

Persistent reflux by age

Treatment

Goal of treatment are

Prevent pyelonephritis
Reflux-related renal injury and other
complication

Surgical and Non-surgical treatment

Use American Urological Association (AUA)
Reflux Treatment Guidelines

American Urological
Association (AUA) Reflux
Treatment Guidelines

Non-surgical theatment

Prophytactic Antibiotics

Age < 2 months Amoxycillin 10 mg/kg/day Once daily hs.

Age > 2 months Cotrimoxazole (Bactrim) of dose Once
daily hs,

Treat voiding dysfunction and constipation

Follow up Repeat U/A , BP measurement
VCUG every 12-18 mo.
Success rate

Reflux grade 1-2 80% in 5 yr.

Reflux grade 3-5 40% in 5 yr.
Reflux grade 3-5 bilat. 10%
Bladder dysfunction No success

Surgical Treatment

Indication

Breakthrough UTI
Severe reflux (Grade 5 or bilateral grade 4)
mild or moderate reflux in females that persists
as the patient approaches puberty
Non-compliance
Poor renal growth/ function
New scars

Surgical Treatment
Open procedure

1.

Modifying the abnormal ureterovesical attachment Intra-mural

ureter length: ureteral diameter 4:1 to 5:1
Megaureter Narrowing to normal size
Poor kidney function - Nephrectomy/Nephroureterectomy

Success rate
Primary reflux grades 1-4 98%
Primary reflux grades 5 80%
Secondary reflux Lower success
2% persistent reflux
1% ureteral obstruction
secondary reflux (posterior urethral valves, neuropathic bladder)
the success rate lower than with primary reflux
No postoperative VCUG

Surgical Treatment
2.

Endoscopic correction

Bulking agent through cystoscope just beneath

ureteral orifice, creating artifical flap valve
Non-invasive out patient procedure
Success rate 70-80%

Endoscopic

correction