Shelly J. King
Children may not present with the typical complaints for a urinary tract infection (UTI), making them a challenge to diagnose and treat. In this case study the child has no complaints, but the parents state the child has urinary urgency and incontinence. As you further investigate, you find the child has infrequent urination and hard stools. She also has a prior visit to the emergency room for similar symptoms and fever.
A UTI is a bacterial infection of the kidneys, bladder, or a combination of both. It is a common cause of febrile illness in children. It can be challenging to diagnose because young children cannot communicate symptoms well. Prompt diagnosis and treatment are essential to minimize acute morbidity and decrease the risk of progressive renal dysfunction. The origin of a urinary tract infection is often unclear. Detailed history, complete data collection, and a physical examination are necessary to provide an individualized plan of care.
1. Apply the guidelines for urinary tract infection management.
2. Determine appropriate interview questions for gathering pertinent data.
3. Discuss variables affecting management, including age, sex, presentation of illness, compliance, and cultural and socioeconomic factors.
4. Identify appropriate testing.
Case Presentation and Discussion
Ashley Jones is a 4-year-old white female who presents in the pediatric clinic for complaints of urinary urgency and foul-smelling urine. Mom describes symptoms of rushing to the bathroom and minor urine leakage during the day over the last 48 hours. She also wet the bed the last two nights. She does not complain of pain with urination and there has been no fever.
Mom reports her concern regarding multiple urinary tract infections over the last year. One infection was associated with fever, flank pain, and vomiting. Mom is very frustrated that this continues to be a problem.
What aspects of the physical examination will be most important?
Upon physical examination, you find Ashley has no specific abnormalities. Her abdomen is soft and nontender; there is no evidence of a mass. Stool is palpable in the right lower quadrant. She denies costal-vertebral angle (CVA) tenderness. You palpate her lower spine and it is normal. There is no visual evidence of any abnormality, no sacral dimple, discolorations, asymmetry, or hair patch. Her feet are not high-arched and her toes are straight. She has no complaints of back pain, lower extremity pain, or weakness. She has full range of motion and ambulates with a normal gait. The external genitalia yield separate urethral and vaginal openings; the perineum is normal aside from some minor irritation. (In males who present with UTI, the scrotal examination is important to rule out epididymitis.) Her vital signs are within normal limits. She is afebrile.
Pathophysiology of Urinary Tract Infection
The majority of urinary tract infections have an ascending route of origin. Despite good perineal hygiene, the perineum and urethral meatus are colonized by intestinal flora that can ascend the urethra into the bladder. Bacterial virulence factors and host susceptibility contribute to development and severity of infection. Escherichia coli accounts for approximately 75–95% of urinary tract infections (Gaylord & Starr, 2009).
Disturbances of bowel and bladder function (dysfunctional elimination syndrome) are common in children with urinary tract infections. A detailed elimination history is important to determine and treat this disorder. Successful management of urinary tract infections will not occur if the elimination pattern is not addressed (Koff, Wagner, & Jayanthni, 1998). Symptoms associated with dysfunctional elimination syndrome (DES) include urinary incontinence, fecal incontinence, constipation, dysuria, urinary frequency and urgency, posturing (such as squatting or crossing legs tightly) to avoid accidents, and infrequent or delayed voiding.
Obstruction and other anomalies of the urinary tract can present with UTI; these infections can be difficult to manage. Vesicoureteral reflux (VUR) is a condition of retrograde flow of urine from the bladder to the kidney. It is graded in order of severity I through V. Children with VUR may be at higher risk for significant infection and resultant renal scarring. Decreased renal function and hypertension can result from renal scarring. Approximately one third of siblings of children with reflux also have reflux, and 50% of offspring of mothers with reflux also have reflux (Elder, 2007).
Epidemiology of Urinary Tract Infection
Bacteruria can occur in all age groups; in the first year of life it is more common in males, especially if uncircumcised (1:47 compared to circumcised 1:445) (Schöen, Colby, & Ray, 2000). After the first year, it is more likely in females (10:1) (Elder, 2007). The short urethra is an accepted explanation for the increased incidence of UTI in girls. By age 11, it is estimated that 1% of males and 3% of females will be affected by UTIs (Alon, 2006).
Social and Economic Factors
Urinary tract infections are common in children. Parents often do not understand the importance of antibiotic use and follow-up. Some believe that home remedies such as cranberry juice effectively treat urinary tract infections. Lack of insurance and difficulties with transportation also often preclude follow-up. These issues need to be respectfully addressed.
Are there lab tests you want to order?
With the symptoms Ashley presents with, a clean-catch, midstream urine specimen would be appropriate to obtain now.
Her urinalysis is leukocyte and nitrite positive today.
What other questions do you want to ask the parents and child to help make the diagnosis?
You want to ask the following questions:
• How often does the child void? (Elimination disturbances)
• Does your child have any stool incontinence or constipation? (Elimination disturbance)
• Does the child have posturing behaviors, or attempts to delay voiding? (Elimination disturbance)
• What symptoms has the child experienced previously?
You need to differentiate between upper tract infection (pyelonephritis) and lower tract bladder infections:
• How were previous urine specimens obtained? Did the child urinate in a cup or was she catheterized? Where were the specimens obtained? (Rule out specimen contamination; the provider needs to determine if the specimens show true infection or a contaminate.)
• Is there any family history of renal anomalies? (Determine genetic risk for renal anomalies.)
• Does the child have any lower extremity pain or weakness? Are there any gait problems? (Neurologic disorders)
• Have you tried any home remedies to help your child? (Homeopathic approach)
Mom responds that Ashley voids infrequently; she sometimes goes up to 2 hours after awakening in the morning before she urinates. During the day, she holds it until the last minute and sometimes they see her squatting or crossing her legs to avoid going to the bathroom. She has occasional damp spots in her underwear during the day, but is typically dry at night; during infections she has accidents both day and night.
The first infection was approximately 9 to 10 months ago. A clean-catch midstream specimen grew 100,000 Escherichia coli. She did not have a fever, flank pain, nausea, or vomiting. Mom had taken her to a clinic because of the incontinence. She was treated with amoxicillin and her symptoms resolved. Six weeks later, mom noticed she had an episode of nocturnal enuresis. At that time, a repeat culture was done, which grew less than 50,000 Escherichia coli. She was treated again, but still had occasional day accidents.
Mom reports Ashley’s bowel movements are infrequent and hard to pass. She has stool streaks in her underwear.
Approximately 2 months prior to this clinic visit, Ashley was seen in the local emergency department with a fever of 102°F. She was complaining of generalized abdominal pain, nausea, and a headache. She vomited several times. She was started on antibiotics and treated as an outpatient. Her urine culture grew greater than 100,000 Klebsiella pneumoniae.
Mom had a history of urinary tract infections as a child, but does not recall being evaluated.
Making the Diagnosis
The differential diagnoses for urinary tract infection include differentiating among upper urinary tract infections (pyelonephritis), lower urinary tract infections, external perineal irritation, foreign body insertion, vaginitis, pin worms, renal calculi, hypercalcuria, constipation, and structural anomalies of the urinary tract such as obstruction or vesicoureteral reflux.
History and physical findings are consistent with the diagnoses of 1) a urinary tract infection, and 2) dysfunctional elimination syndrome. The urinalysis is both leukocyte and nitrite positive and should be sent to the laboratory for culture and sensitivity.
How a specimen is collected directly correlates to its validity: most valid is suprapubic bladder aspirate, second is sterile urethral catheterization, and third is clean-catch midstream. The least reliable is the bagged specimen (Gaylord & Starr, 2009).
Ashley has no known allergies. She has delayed voiding, posturing to prevent enuresis, and constipation, which are symptoms consistent with dysfunctional elimination syndrome. There is one documented upper tract infection with fever, nausea, and vomiting. Pyelonephritis may be indicative of structural abnormality and warrants additional evaluation. Structural abnormalities such as VUR, obstruction, or other anatomical defects may present as urinary tract infection (Gaylord & Starr, 2009).
The treatment plan is determined by the findings of urinary tract infection, dysfunctional elimination syndrome, and any complications such as vesicoureteral reflux. It will be customized to the child’s age.
The goals are to:
• Protect the kidneys from damage.
• Prevent urinary tract infections.
• Resolve dysfunctional elimination syndrome.
• Monitor vesicoureteral reflux.
• Educate the family on how to achieve the above goals.
What additional studies are necessary to confirm the diagnosis?
Urine culture and sensitivity are indicated to identify the causative organism and specific antibiotic management. Febrile infection and more than one infection in a child less than 5 years of age require evaluation by a renal and bladder ultrasound and voiding cystourethrogram (Shortliffe, 2007).
What is the first thing you need to do to manage her UTI?
Ashley should be started on antibiotics empirically. Two months ago she was seen in the ED, at which time her urine specimen grew greater than 100,000 colonies of Klebsiella pneumoniae. She was treated in the ED with a single dose of ceftriaxone and discharged on oral cephalexin. The culture was sensitive to the prescribed treatment and sulfamethoxazole. Today’s clinical symptoms are consistent with a lower tract bladder infection; she does not have fever, flank pain, nausea, or vomiting, which are symptoms of pyelonephritis. She is started on trimethoprim-sulfa; when she finishes the treatment dose, she will be started on prophylaxis. Trimethoprim-sulfa is a good choice; it is inexpensive, does not need to be refrigerated, has a relatively long shelf life, and is unlikely to cause gastrointestinal upset. The side effect profile overall is low.
Antibiotic prophylaxis is appropriate for a child with a history of a febrile infection, until she has been evaluated fully. She is at risk for anatomical abnormalities and should be maintained on prophylaxis until her X-ray evaluation is complete (Gaylord & Starr, 2009).
Further Diagnostic Studies
A renal and bladder ultrasound is used to rule out kidney abnormalities, and a voiding cystourethrogram is obtained to rule out vesicoureteral reflux or bladder abnormalities. In children, it is important to discover anatomical sources for bacterial persistence that may necessitate surgical intervention (Shortliffe, 2007). A renal and bladder ultrasound and voiding cystourethrogram should be obtained in any child with a febrile urinary tract infection, any male child, and any infant or child under age 5 (Shortliffe). Patients with hydronephrosis or grade IV–V VUR should be referred to a pediatric urologist.
An X-ray evaluation was obtained. An ultrasound shows normal kidneys, with a significant postvoid residual. A voiding cystourethrogram (VCUG) shows grade II vesicoureteral reflux into the right renal pelvis. She did not empty her bladder on VCUG and has a spinning-top urethra, the classic finding of detrusor sphincter dyssynergia. Detrusor sphincter dyssynergia is a lack of coordination between the bladder contraction and relaxation of the external sphincter. This discoordination leads to incomplete evacuation of the bladder. A KUB (kidneys, ureters, and bladder) X-ray typically precedes the VCUG, and in Ashley’s case reveals a moderate stool burden. Constipation may provoke detrusor-sphincter activity. The bony structure of the spine appears normal. The X-ray evaluation is consistent with dysfunctional elimination and vesicoureteral reflux.
How do you plan to manage her dysfunctional elimination syndrome?
Dysfunctional Elimination Syndrome
Dysfunctional elimination must be addressed regardless of the results of her X-ray evaluation. She needs to be placed on a timed voiding regimen during the day. She is in the habit of holding her urine to the point of having urge incontinence. Often these children have difficulty relaxing the external sphincter and do not take time to void to completion. This is complicated by constipation, which increases colonization of the intestinal flora and may create difficulty with voiding to completion.
You explain to the mother that Ashley’s dysfunctional elimination will be managed by placing her on a strict timed voiding schedule during the day, every 2 hours by the clock, whether she has the urge to urinate or not. You suggest using a simple behavioral modification chart with days of the week and times of the day for scheduled voiding, which can be created with stickers to recognize her cooperation with the plan.
During today’s visit, Ashley is trained in the proper toileting posture to facilitate relaxation of the external sphincter and voiding to completion (Yeung, Sihoe, & Bauer, 2007). She is instructed to sit on the toilet with her legs widely separated. She should be sitting comfortably on the toilet with her feet supported. In small children this requires a seat adapter.
For constipation, she will be given a cleanout regimen, a pediatric Fleet enema given once a day for 2 to 3 days. A stool softener is also started and can be tapered as the stools become normal. There are many effective bowel management programs. The family is instructed on a high-fiber diet and increasing fluids during the day.
Urinary Tract Infection and Vesicoureteral Reflux
Ashley is started on trimethoprim-sulfamethoxazole treatment dose and then will be maintained on prophylaxis. Trimethoprim-sulfamethoxazole can be used in children older than 2 months of age. The treatment dose is based on trimethoprim 6–12 mg/kg/day given BID for 10 days. The prophylaxis dose is also based on trimethoprim, but at 1–2 mg/kg/day. Trimethorprim-sulfamethoxzzole diffuses into vaginal fluid and decreases bacterial colonization.
Macrodantin or furadantin elixir is another effective treatment and/or prophylactic agent. It does not achieve high blood levels and should not be used for systemic or febrile infections. The most common side effect is gastrointestinal upset. To help prevent this problem, the medication should be given with food. The liquid form is not tolerated well by children. The capsules can be opened and sprinkled on applesauce, yogurt, or pudding. It can be given to children older than 2 months of age, and the treatment dose is 5–7 mg/kg/day given QID. Prophylaxis is 1–2 mg/kg/day in a single dose.
Amoxicillin is also used to treat urinary tract infections and is often used for prophylaxis in children under 3 months of age. It is tolerated well and has a low side effect profile, but can cause candidiasis in high doses. The suspension has to be refilled every 14 days, which makes it less convenient for families to use. Prophylaxis is 20 mg/kg/day in a single dose. Treatment dosing of amoxicillin is variable, based on age and severity of infection. Cephalosporins can also be used for treatment and/or prophylaxis.
Antibiotic management of pediatric UTIs is always done with caution. Age-related dosing restrictions, comorbid conditions, and severity of infection must be considered before treatment is recommended. These issues also affect the decision of whether to utilize inpatient intravenous therapy versus outpatient oral management. Children who appear toxic and those under 2 months of age who have suspected pyelonephritis should receive intravenous treatment. Ampicillin and aminoglycoside (if no known drug allergy) are started until culture and sensitivity results are final (Brown, Burns, & Cummings, 2002). Fluoroquinolones have been approved by the Food and Drug Administration (FDA) for the treatment of complicated UTIs in children. In children who present with a febrile UTI but do not appear toxic, 1 to 2 days of intramuscular ceftriaxone can provide coverage until culture results are final and appropriate oral therapy is determined
The family should be educated on the signs and symptoms of a UTI at this appointment. They should be able to differentiate between a significant upper tract or kidney infection and lower tract symptoms or bladder infection. With a history of vesicoureteral reflux, at the first sign of infection the child should be evaluated. The signs and symptoms of UTI should be revisited when discussing the X-ray evaluation with the family. If a urinalysis is positive, treatment should be started before culture results have been received to prevent the development of pyelonephritis. Vesicoureteral reflux should be evaluated by ultrasound and VCUG every 12 to 18 months. As long as the child has good overall renal growth, no evidence of scarring, no infections while on prophylaxis, and no worsening reflux, the child can be managed conservatively. If they have breakthrough infections or upper tract changes, alternate management would need to be considered. This would warrant a referral to a pediatric urologist. Other variables that might lead to surgical management are allergies to multiple antibiotics and poor compliance with medical management.
You provide patient education as follows:
Explain the diagnosis, pathophysiology, and typical progression of the disorder.
Explain that antibiotics are necessary to hopefully prevent urinary tract infection. They do not treat or resolve vesicoureteral reflux.
Discuss the use of oral antibiotics, the importance of giving them on a routine basis, and completing any treatment antibiotics that are prescribed.
Discuss potential side effects of antibiotics and any evaluation that is necessary.
Reassure the family that with urinary tract infection prevention, the child will likely do well. It does require patience, however, to work with children this young to modify behavior.
Provide positive reinforcement to the child for practicing the toileting habits that improve bladder and bowel emptying.
Instruct parents to bring the child to the clinic for prompt evaluation of urine if there are any signs or symptoms of urinary tract infection.
Discuss the importance of dysfunctional elimination management to prevent infection and promote VUR resolution.
Ashley is only 4 years old, but you tell her in simple terms about:
the specific toilet posture to facilitate emptying (have the child demonstrate in the office)
the importance of not delaying urination or stooling
the use of a chart and stickers to reward her efforts
the importance of an appropriate diet and fluid intake to decrease symptoms of constipation
When do you want to see this patient back again?
Renal ultrasound and voiding cystourethrogram should be obtained about 10 days after beginning treatment of a UTI. A time should be scheduled to review results with family, recheck the urine, and determine compliance with dysfunctional elimination management and antibiotic prophylaxis. An abdominal examination should be performed to assess for constipation. The bladder should not be percussible after voiding if the child is emptying well.
At the next visit 2 weeks later, Ashley is taking her antibiotics on a daily basis. She has been working hard on voiding every 2 hours and has been practicing the voiding techniques to help empty her bladder. Her abdomen is soft and nontender, and there is no evidence of a mass indicating constipation. The parents report that she is having a daily bowel movement that is soft and not painful. Her bladder is not percussible, and her urinalysis today is negative. Renal ultrasound and VCUG results are normal.
The plan will be to see her back in 6 to 8 weeks. If she continues to do well, then surveillance could be spread out to 6 months and then a year. At that point, her ultrasound and VCUG should be repeated.
There are rare cases in which children with dysfunctional elimination, UTI, and reflux have symptoms that persist or worsen, even with appropriate management. This outcome could indicate a neurologic abnormality, so evaluation of the lower spine by MRI may need to be done. Other symptoms that can be associated with neurologic issues are chronic back and lower extremity pain, gait abnormalities, and stool incontinence. Physical evidence of bony abnormalities can sometimes be seen on plain radiographs, or as sacral dimples, gluteal asymmetry, lower spine discolorations, or a sacral hair patch.
Key Points from the Case
1. Guidelines simplify the care of recurrent urinary tract infections, vesicoureteral reflux, and dysfunctional elimination syndrome.
2. Treatment of dysfunctional elimination syndrome, reflux, and urinary tract infection requires an understanding of the pathophysiology and development of the patient and a family care plan.
3. Urinary tract infections will not improve unless dysfunctional elimination is addressed.
4. Significant abnormalities of the urinary tract can present with urinary tract infection and must be kept in mind when evaluating a patient.
5. Antimicrobial management is dependent on age, comorbid conditions, and severity of infection.
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Brown, J., Burns, J., & Cummings, P. (2002). Ampicillin use in infant fever: a systematic review. Archives of Pediatric and Adolescent Medicine, 156, 27–32.
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