Dr MJ Engelbrecht Dept Urology University of Pretoria Urinary tract infections and congenital urological abnormalities in children Dr MJ Engelbrecht Dept Urology University of Pretoria

Urinary tract infection in children 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

UTI in Children Diagnosis Interpretation Urine bag Suprapubic aspiration Midstream urine specimen Interpretation Culture Midstream or urine bag collected specimen Single organism > 100000 organisms/ml Any number of organism is significant

UTI in children Which UTI should be investigated Investigations ALL FIRST INFECTIONS MUST BE INVESTIGATED Investigations Under 2 years U/S KUB VCUG Over 2 years VCUG only if Abnormal ultrasound Temperature more than 38 degrees

UTI in children Abnormalities found (50% of children) VUR Obstruction 85% of urinary tract abnormalities Obstruction Posterior urethral valves PUJ Obstruction Primary obstructive megaureter Ureterocele Other Neurogenic bladder Calculi

Vesico urethral reflux 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.

Classification Primary reflux Secondary reflux Short submucosal tunnel N - Neurogenic bladder O - Obstruction T - Trauma or surgery I - Infection C - Congenital ureteric abnormalities E - Ectopic ureteric openings

Prevalence 1-2 % of children 20 – 30 % of children with UTI Outosomal dominant genetic disorder 30% in siblings 50% in offsprings

Complications Reflux nephropathy Hypertension Chronic renal failure 20% of pediatric renal transplant patients have reflux nephropathy

Diagnosis VCUG Indirect nuclear cystography Ultrasound “gold” standard Done after the UTI has been treated Advantages Grades reflux Excludes secondary causes of reflux Indirect nuclear cystography Ultrasound

Diagnosis VCUG

Treatment 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

Treatment Surgical Indications Endoscopic treatment Open surgery 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)

PUJ Obstruction 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

Complications 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

Diagnosis Ultasound IVP MAG 3 renogram First investigation Will show hydronehrosis with normal ureter IVP Show dilated renal pelvis with normal ureter MAG 3 renogram

Diagnosis

Treatment Conservative Surgical If no complications and > 40% differential function Regular follow up with renal ultrasound Surgical Indications Decrease in differential function Complications UTI Renal failure Calculi

Treatment Surgical Open surgical Endoscopic Laparoscopic Nephrectomy Pyeloplasty Endoscopic Endopyelotomy Balloon dilatation Laparoscopic Nephrectomy If non fuctioning kidney

Posterior Urethral Valves Thin membrane obstructing the urethra distal to the verumontanum This cause proximal urethral dilatation, severe bladder trabeculation and bilateral hydronephrosis

Presentation 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

In the acute setting Acute management Resuscitation Urethral catheter Fluids Electrolytes Correct Acid base balance Treat UTI Urethral catheter Will relieve obstruction This will allow urosepsis and renal failure to resolve

Diagnosis Ultrasound VCUG Will show Confirms the diagnosis bilateral hydronephrosis and hydroureter Thickened bladder wall Dilated posterior urethra VCUG Confirms the diagnosis Trabeculated bladder VUR (Secondary reflux)

Treatment 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