During 1st year of life
• females 4.2%
• male uncirc 4.1%
• male circ 0.1-0.2%
UTI vs pyelo in an infant is a hard ddx.
Reflux in 30%.
Clin: fever s source. Can have vomit, diarrhea, poor feed, etc.
To do:
• Cx (pre-abx) via cath or suprapubic aspiration: bag (62.8% aspiration), cath
(9.1%)
• 20% of u/a can be neg, therefore get cx
• u/a alone is no good. LE has poor specificity, nitrites poor sensitivity
• get VCUG 48 h post start ABX
• All babies with 1st UTI get renal US and VCUG
• (+) cx when >105 CFU/mL
• IVP - adults only. radiation to gonads.
Tx:
• Get sensitivities. There is high resistance to amoxicillin.
• bactrim prophylaxis
• surgery for high grade reflux (low grade = 1-2)
• if reflux is >=2, DMSA scan 4-5 mos post. Because it takes that long to form
scars. Tc99 lights scarred areas.
Bug
• gram (-) orgs: E. coli
• if multi-orgs, then likely contaminants
Prophylaxis:
• bactrim, macrodantin
Other questions:
I am working in private practice now and I was wondering if I could ask you a couple questions: 1. I have a 10 mons boy who presented to ER with fever of 104-105 for 2 days (No URI sxs). CBC showed WBC of 36,000 (very high) and the UA showed trace leuk, micro showed 10-25 WBC and moderate bacteria. (negative nitrite and blood). I put him on Keflex when I saw him in the office the next day. However, I got the urine culture back and it was totally negative!! (it was a cath'd specimen). I was extremely shocked! Should I treat it as a real UTI? I was quite convinced that it was UTI. Does he need all the work-up AND prophylactic ABX?
THIS SEEMS LIKE A REAL UTI TO ME TOO, ESPECIALLY IF YOU DO NOT HAVE ANOTHER SOURCE OF INFECTION. I DON'T KNOW WHY THE CULTURE WOULD BE NEGATIVE EXCEPT THAT SOMETIMES THEY DO MIX UP SPECIMEN, OR THE KID MIGHT HAVE HAD SOME ABX PRIOR TO THE CULTURE, OR IT WAS AN ORGANISM THAT IS NOT ROUTINELY TESTED, SUCH AS UREAPLASMA, YEAST, OR TB (UNCOMMON CAUSES OF UTI IN CHILDREN). AS THE UTI IS NOT CONFIRMED BY CULTURE, BUT THE SUSPICION IS PRESENT, I WOULD JUST OBTAIN A RENAL ULTRASOUND FOR NOW. IF IT IS NOT NORMAL, THEN I WOULD GET A VCUG. I WOULD NOT KEEP HIM ON PROPHYLAXIS YET, UNLESS THE MOTHER TELLS US A HISOTRY OF PRENATAL RENAL ABNORMALITY IN THE KID.
2. When should we refer kids to Urology in terms of
reflux grade? Should they be on prophylactic abx if
VCUG and u/s totally normal?
THE TIMING OF REFERRAL VARIES FROM PEDIATRICIAN TO PEDIATRICIAN.
SOME REFER TO US VERY EARLY, BEFORE DIAGNOSING THE REFLUX; OTHERS HAVE IT ALL
WORKED UP AND THE PARENTS COME TO SEE US TO DECIDE WHETHER TO DO SURGERY.
IN GENERAL, GRADE 1 VUR BY ITSELF RARELY NEEDS SURGERY.
IF YOU ARE COMFORTABLE FOLLOWING CHILDREN WITH REFLUX MEDICALLY (WE DO A LOT OF IT OURSELVES, NOT EVERYONE NEEDS SURGERY), MY RECOMMENDATIONS ARE:
1. KEEP ALL CHILDREN WITH REFLUX ON PROPHYLACTIC ANTIBIOTICS
2. FOR CHILDREN UNDER 5, GET A RENAL ULTRASOUND EVERY 6 MONTHS
AND A VCUG/NUCLEAR CYSTOGRAM EVERY 1-2 YEARS. LOOK FOR RENAL SIZE SYMMETRY,
IMPROVEMENT (OR LACK OF) IN THE DEGREE OF REFLUX, ANY ASSOCIATED ANOMALIES
3. AFTER AGE 5, THE RENAL ULTRASOUND CAN BE DONE EVERY 1-2 YEARS AND THE VCUG EVERY 2-3 YEARS, ASSUMING THE CHILD IS FREE OF INFECTIONS AND EVERYTHING HAS BEEN NORMAL
4. THE ANTIBIOTICS CAN BE STOPPED, ASSUMING THE CHILD HAS BEEN FREE OF UTI'S, AFTER AGE 7. THERE IS NO HARD EMPIRICAL DATA ON THIS, BUT AT THIS AGE, THE MAJOR GROWTH PHASE OF THE KIDNEYS IS PAST, AS WELL AS MOST OF THE DYSFUNCTIONAL VOIDING PATTERNS.
WHEN TO REFER (INDICATIONS FOR SURGICAL INTERVENTION), NOT IN
ORDER OF IMPORTANCE
1. WHEN YOU ARE NOT COMFORTABLE FOLLOWING CHILDREN WITH ANY GRADE
OF REFLUX LONG-TERM (USUALLY SEVERAL YEARS, ALTHOUGH JUST 1-2 TIMES PER YEAR)
2. HIGH GRADE REFLUX (4-5)
3. THE CHILD HAS BREAKTHROUGH UTI'S ON PROPHYLACTIC ANTIBIOTICS
or THERE IS ISSUE WITH MEDICAL COMPLIANCE
4. THERE IS RENAL SIZE ASYMMETRY (>1 cm), RENAL SCARRING,
WORSENING REFLUX ON FOLLOW-UP IMAGING
5. ASSOCIATED ANOMALIES: CONCOMITANT OBSTRUCTION AT UVJ (MEGAURETER),
POSTERIOR URETHRAL VALVES, NEUROGENIC BLADDER, DIVERTICULUM, URETERAL
DUPLICATION, URETEROCELE, ECTOPIC URETER, CONTRALATERAL UPJ OBSTRUCTION,
MULTICYSTIC RENAL DYSPLASIA, PRUNE BELLY SYNDROME, ECT, ETC.
6. PARENTS WANT TO KNOW WHAT SURGICAL OPTIONS ARE (ENDOSCOPIC VS. OPEN SURGICAL VS. LAPAROSCOPIC)
WHEN TO GIVE PROPHYLACTIC ABX
1. WHEN REFLUX IS PRESENT, OR WHEN THERE IS HIGH GRADE
OBSTRUCTION AWAITING SURGERY (EG. UPJO)
2. WHEN WORK-UP IS NEGATIVE BUT CHILD HAS RECURRENT CYSTITIS (>2
IN 6 MON). AN INFLAMMED BLADDER IS MORE PRONE TO UTI SO IT WOULD BE A GOOD IDEA
TO HELP IT HEAL A BIT.
3. AT what age do you consider "phimosis" abnormal? I was told 5 years old at residency but now people are
saying more like 7. Shoudl we refer to urology right away or should we try Betamethasone cream first?
THERE IS NO SET AGE, BUT APPARENTLY BY SOME REPORT
>90% OF BOYS
SHOULD HAVE FULLY RETRACTIBLE FORESKIN BY AGE 3. BUT IT CERTAINLY SEEMS TO ME
THAT MANY MORE BOYS HAVE NON-RETRACTABLE FORESKIN AT THAT AGE. IN ANY CASE, I
JUST TELL THE PARENTS TO AVOID PULLING IT DOWN FORCIBLY, AS THAT WILL TEAR THE
SKIN, CAUSE BLEEDING AND INFECTION, AND END UP WITH A SCAR THAT WILL NOT ALLOW
FURTHER RETRACTION AND THAT DOES NOT RESPOND TO STEROID CREAM. THERE IS
NO NEED
TO WASH INSIDE THE FORESKIN. THE SMEGMA THAT ACCUMULATE UNDERNEATH, SOMETIMES
FORMING 'PEARLS', WILL EVENTUALLY WORK ITS WAY OUT LIKE EARWAX DOES.
UPON
ERUPTION, IT MAY CAUSE SOME BLEEDING, REDNESS, PAIN, AND EVEN MILD FEVER. JUST
HAVE THE PARENTS PUT SOME ANTIBIOTIC OINTMENTS ON THE EDGES AND IT WILL BE FINE.
I LIKE THE 0.05% BETAMETHASONE CREAM BID X 1 MON. BUT IT IS NOT COVERED BY MEDI-CAL. FOR MEDI-CAL PATIENTS, I USE TRIAMCINOLONE 0.1% BID FOR ONE MONTH ALSO. UNLESS THE PARENTS COME IN BEGGING TO HAVE THE CHILD CIRCUMCISED (USUALLY AFRICAN AMERICANS, KOREANS, FILIPPINOS PREFER TO HAVE THEIR BOYS CIRCUMCISED), I USUALLY TRY THE CREAM FIRST. SO PLEASE TRY THE CREA BEFORE REFERING TO US. THE LATINOS USUALLY WILL ASK THAT THEIR CHILD NOT BE CIRCUMCISED. IN THIS CASE, A DORSAL SLIT CAN BE MADE UNDER ANESTHESIA. INCIDENTALLY, THE FEELING BY THE LATINOS NOT TO HAVE THE CHILD CIRCUMCISED IS SO STRONG THAT I HAVE RECENTLY DEVELOPED TECHNIQUES TO REPAIR HYPOSPADIAS WITHOUT REMOVING THE FORESKIN, LEAVING THE CHILD WITH AN UNCIRCUMCISED APPEARANCE. I THINK SO FAR I AM THE ONLY ONE DOING IT THIS WAY AT CHLA. IT HAS WORKED OUT SATISFACTORILY SO FAR.
NEARLY ALL BOYS ARE BORN WITH NORMAL PHYSIOLOGIC PHIMOSIS. ABNORMAL PHIMOSIS IS PRESENT WHEN IT CAUSES SYMPTOMS: POSTHITIS (FORESKIN INFECTION), Balanitis (GLANS INFECTION), BALANOPOSTHITIS, FORESKIN SWELLING WHEN URINATING, URINARY RETENTION (RARE), UTI'S, OR HISTORY OF PARAPHIMOSIS (USUALLY FROM EAGER PARENTS WHO PULL BACK THE SKIN TO CLEAN IT BUT COULD NOT REDUCE IT TO NORMAL POSITION, OR FROM A NURSE/TECH PUTTING IN A CATHETER FOR CULTURE OR VUCG). I TEND TO LEAVE ALL FORESKIN ALONE UNLESS ONE OF THE ABOVE HAPPENS. THE STEROID CREAM WORKS BEST WHEN THERE HAS NOT BEEN PRIOR INFECTION (WHICH CAUSES SCARRING). IF PARENTS ARE CONCERNED AT ALL, I WOULD START WITH THE CREAM REGARDLESS OF THE AGE.
Best regards to all,
Andy Hwang
Division of Urology
213-203-0651 pager
323-669-2334 direct
323-669-2247 appointments
Other members of the Division of Urology
Brian Hardy, M.D. (Chief)
Roger De Filippo, M.D.
Leonard Skaist, M.D. (part-time)