FIGURE 4.2.  DMSA scan of 10 year old girl with persistent grade II VUR bilaterally and recurrent UTIs managed medically showing bilateral renal scarring. The black areas are functioning renal tissue and the pale punched out areas are scars. Left kidney (red ring) functions poorly compared to the right kidney (green ring).

a clear idea of differential renal function and distribution of renal scarring. It can also been used acutely to diagnose acute pyelonephritis (Fig. 4.2).

4.6  Prevention of UTIs

Important practices to minimize the risk of UTIs include:

•Prophylactic antibiotics

Up to now, there was no strong evidence to support the role of prophylactic antibiotics after a single UTI in preventing recurrences.A recent Australian randomized control trial is the first to definitively show a reduction in the risk of UTIs in the 12 months after the index UTI in the group of children placed on daily trimethoprim/sulphamethoxazole.5

42 N. Samnakay and A. Barker

However, the protective effect seemed to drop off with time, and the long term benefit of antibiotic prophylaxis in children with UTIs remains unproven.

•Managing dysfunctional elimination

Dysfunctional voiding, with raised post-void residual volumes and constipation, are associated with an increased risk of urinary tract infections and hence must be carefully investigated and managed, particularly in children who present with recurrent UTIs.

•Cranberry juice

Contains anthocyanidin/proanthocyanidin moieties that are potent antiadhesion compounds and thought to prevent I and P-fimbriated uropathogens such as E. coli from adhering to the urothelium. There is randomized evidence that cranberry helps reduce the risk of recurrent UTIs in adult women, and its value in children is extrapolated but not proven.12

•Probiotics

Thought to promote the balance of bowel organisms in favor of non-pathogenic commensals.

•Circumcision in male infants

Studies suggest that circumcised boys have a tenfold lower risk of UTI compared with uncircumcised boys.13, 14 However, there is no evidence to recommend circumcision for all boys after a first UTI. Circumcision is certainly considered in boys who get recurrent UTIs and have underlying urinary tract anomalies such as posterior urethral valves or VUR.

•Drinking plenty of fluids

•Good toileting habits

These include regular 3 hourly voids, and wiping the perianal area away from urogenital area.

4.7  Managing VUR and UTIs

Most low grade VUR resolves spontaneously. For higher grade VUR, parents are given the choice of prophylactic antibiotics and waiting for possible spontaneous resolution, or surgical intervention to correct the VUR.

Data from the Cochrane Review show a 50% reduction in the risk of febrile UTIs in children after surgical treatment for VUR.15 Surgical treatment options for VUR include:

•Endoscopic injection of ureteric orifice with substances like Deflux gel. This has an 80% success rate in correcting the VUR in correcting VUR after the first injection. It is done as day-case surgery under general anesthetic and can be repeated if VUR persists.

•Open surgical ureteric reimplantation. This has a 98% + success rate in correcting VUR. It involves a small suprapubic incision and 1–3 days in hospital recovering.

References

1.Marild S, Jodal U. Incidence rate of first-time symptomatic urinary tract infection in children under 6 years of age. Acta Paediatr. 1998;87(5):549-552.

2.Hellstrom A et al. Association between urinary symptoms at 7 years old and previous urinary tract infection. Arch Dis Child. 1991;66(2):232-234.

3.Linda S. Urinary Tract Infections in Infants and Children. In: Walsh P, ed. Campbell’s Urology, vol. 3. Baltimore: Saunders; 2002.

4.Bauer R, Kogan BA. New developments in the diagnosis and management of pediatric UTIs. Urol Clin North Am. 2008;35(1):47-58. vi.

5.Craig JC et al. Antibiotic prophylaxis and recurrent urinary tract infection in children. N Engl J Med. 2009;361(18):1748-1759.

6.Giorgi LJ Jr, Bratslavsky G, Kogan BA. Febrile urinary tract infections in infants: renal ultrasound remains necessary. J Urol. 2005;173(2):568-570.

7.Coulthard MG, Lambert HJ, Keir MJ. Occurrence of renal scars in children after their first referral for urinary tract infection. BMJ. 1997;315(7113):918-919.

44N. Samnakay and A. Barker

8.American Academy of Pediatrics. Committee on Quality Improvement. Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children.Pediatrics. 1999;103(4 Pt 1):843-852.

9.Royal College of Physicians. Guidelines for the management of acute urinary tract infection in childhood. Report of a working group of the research unit. J R Coll Physicians Lond. 1991;25(1): 36-42.

10.National Collaborating Centre for Women’s and Children’s Health.

Urinary Tract Infection in Children: Diagnosis, Treatment and LongTerm Management. London, UK: National Institute for Health and Clinical Excellence; 2007.

11.Williams G et al. Ordering of renal tract imaging by paediatricians after urinary tract infection. J Paediatr Child Health. 2007;43(4): 271-279.

12.Jepson RG, Craig JC. Cranberries for preventing urinary tract infections. Cochrane Database Syst Rev. 2008(1):CD001321.

13.Wiswell TE et al. Declining frequency of circumcision: implications for changes in the absolute incidence and male to female sex ratio of urinary tract infections in early infancy. Pediatrics. 1987;79(3): 338-342.

14.Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics. 2000;105(4 Pt 1):789-793.

15.Hodson EM et al. Interventions for primary vesicoureteric reflux. Cochrane Database Syst Rev. 2007(3):CD001532.