1. ROLLO CLIFFORD

2.  Diagnosis  Treatment  Assessment:  History  Examination  Referral

4.  Reduced feeding or Vomits more than usual.  Fever with no other obvious explanation.  Sleepy and lethargic  Stops gaining weight or unexpected loss.  Has jaundice which gets worse when more than a week old.  (Unusual smell to urine)  (Seems to be in pain at times and when urine is passed)

6.  MSU, CCU, OK – Bag not.  Stick test – if positive to nitrites or leucocytes, lab sample + consider Rx.  Lab sample as urgent if: ◦ Known urinary tract anomaly ◦ Symptoms suggestive of pyelonephritis ◦ Under 3 years with suggestive symptoms  White cap bottle if small sample but to labe quickly.

8.  Treat rapidly if upper tract features  Infants nearly always in this category  Amoxycillin excellent – if sensitive – toss a coin?  Trimethoprim/Augmentin/Cephalexin  Follow up and check sensitivities

10.  Initial symptomatology  Fever  Vomiting  Site of any pain/discomfort  Diagnostic accuracy – method of urine collection

11.  Previous infections / undiagnosed fevers  Recurrent loin pain  Possible neurological symptoms  Family history – renal anomalies, renal failure, hypertension

12.  Dysfunctional Elimination Syndrome  Urge syndrome  Staccato voiding  Fractional and incomplete voiding  Voiding postponement  Constipation / Stool retention / Enuresis Soiling  Vaginal reflux

13.  Fluid intake – too few drinks or, in some cases, interfering with appetite.  Hygiene – bubble baths, washing hair in bath, frequency, wiping, odour.  Symptoms suggestive of thread worm infection.  School toilets and access

14. Plotted height and weight with comparison with previous centiles Blood pressure measurement Abdominal examination Genital examination in pre-pubertal children (unless recorded normal elsewhere) Urinalysis

15. For all under 4 or in referral categories  Renal size  Dilation of collecting system and ureter  Bladder emptying  Congenital abnormality  Large calculi  No – ionising radiation  Atraumatic  Costs about 1/10 of an isotope scan

16.  Exclude scarring  Exclude reflux – which may predispose to future scarring.

18.  Symptoms of cystitis only – i.e. No upper tract symptoms  Age >12 months  Clear diagnosis  Normal ultrasound  Single infection  Associated factors e.g. Constipation/soiling, manageable in primary care  Time to make above assessment with confidence.

19.  Recogntion of infection (infants especially)  Prevention of future infection ◦ Bladder habit ◦ Hygiene issues ◦ Diet (incl. fluids) and Constipation  Provide leaflet

20.  Severe systemic upset  Inadequate fluid intake/vomiting  Infants

21.  Any upper tract symptoms – fever >38, loin pain, vomiting, obvious systemic upset.  Two or more infections  Any abnormality on ultrasound.  Diagnostic doubt  Associated risk factors which prove difficult to manage – e.g. constipation/soiling.  GP preference

22.  Symptoms or ultrasound findings suggest severe obstruction (e.g. Possible urethral valves / gross renal or ureteric dilation on ultrasound – particularly if during infancy and if bilateral)