Dr MJ Engelbrecht
Dept Urology
University of Pretoria


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

Diagnosis




Urine bag
Suprapubic aspiration
Midstream urine specimen
Interpretation

Culture
 Midstream or urine bag collected specimen
 Single organism > 100000 organisms/ml
 Suprapubic aspiration
 Any number of organism is significant

Which UTI should be investigated


ALL FIRST INFECTIONS MUST BE
INVESTIGATED
Investigations

Under 2 years
 U/S KUB
 VCUG

Over 2 years
 U/S KUB
 VCUG only if
 Abnormal ultrasound
 Temperature more than 38 degrees


Abnormalities found (50% of children)
VUR


Obstruction





85% of urinary tract abnormalities
Posterior urethral valves
PUJ Obstruction
Primary obstructive megaureter
Ureterocele
Other


Neurogenic bladder
Calculi


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.


Primary reflux


Short submucosal tunnel
Secondary reflux
N
 O
 T
 I
 C
 E

-
Neurogenic bladder
Obstruction
Trauma or surgery
Infection
Congenital ureteric abnormalities
Ectopic ureteric openings



1-2 % of children
20 – 30 % of children
with UTI
Outosomal dominant
genetic disorder


30% in siblings
50% in offsprings



Reflux nephropathy
Hypertension
Chronic renal failure

20% of pediatric renal transplant patients have reflux
nephropathy

VCUG



“gold” standard
Done after the UTI has been treated
Advantages
 Grades reflux
 Excludes secondary
causes of reflux


Indirect nuclear
cystography
Ultrasound

VCUG

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

Surgical

Indications






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)


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
-

In the wall
-
Stone or
blood clot
Stricture
from
infection or
trauma







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

Ultasound



IVP


First investigation
Will show
hydronehrosis with
normal ureter
Show dilated renal
pelvis with normal
ureter
MAG 3 renogram

Conservative



If no complications and > 40% differential function
Regular follow up with renal ultrasound
Surgical

Indications
 Decrease in differential function
 Complications
 UTI
 Renal failure
 Calculi

Surgical

Open surgical
 Pyeloplasty

Endoscopic
 Endopyelotomy
 Balloon dilatation


Laparoscopic
Nephrectomy
 If non fuctioning
kidney


Thin membrane obstructing the urethra distal
to the verumontanum
This cause proximal urethral dilatation, severe
bladder trabeculation and bilateral
hydronephrosis



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


Acute management

Resuscitation
 Fluids
 Electrolytes
 Correct Acid base balance
 Treat UTI

Urethral catheter
 Will relieve obstruction
 This will allow urosepsis and renal failure to resolve

Ultrasound

Will show
 bilateral hydronephrosis
and hydroureter
 Thickened bladder wall
 Dilated posterior urethra

VCUG
Confirms the diagnosis
 Will show

 Dilated posterior urethra
 Trabeculated bladder
 VUR (Secondary reflux)

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