Urine Infections
We thank and congratulate Dr. Didsbury and her colleagues for highlighting the problem of urine infections in children and for the quality of their presentation.
An aspect of consideration of information pertaining to urine infection is that Paediatric Urologists have long been able to record and share endoscopic images, yet the inclusion of that information in multidisciplinary meetings has not become routine, despite the ability of the additional information in some cases giving better insight into the wider population of children. Our recent review highlights the resistance of some practitioners to the routine use of endoscopic recording, noting, however, that proceeding to investigation under general anaesthetic should be relatively rare.
A more clinical point, that was not highlighted in the paper, is the importance of genital examination, as we have had a number of patients who come for review after an admission, yet the presence of severe labial adhesions or phimosis was missed.
Also, the authors in their Table 2 give urine infection criteria related to the culture result rather than a combination of the white cell count and culture result. A high white count and no growth could be due to the infective organism not being isolated for technical reasons. A positive growth and no white cells is probably contamination.
A further point about Table 2 is that infection can be diagnosed on a bag specimen, but in a child unwell from a urine infection, other collection mechanisms are more reliable. However, there are widely diverse circumstances, and a bag specimen is part of the armamentarium of the evaluation of the patient.
We note that the authors are of the view that “increasingly, imaging is avoided for simple first-time UTI, due to the time, expense, and worry it may cause,” whereas we would contend that a renal ultrasound in a proven urine infection (with a raised white cell count) is similar to measuring blood pressure – simply a recording of related information that is not immediately visible. Therefore, we recommend an ultrasound for every proven first urine infection and that an ultrasound is repeated, in some circumstances, if infections are recurrent. For a febrile infection in an unwell child, the ultrasound should be done as an emergency, as significant obstructive pathology may exist.
Furthermore, the authors contend that “MCUs are usually avoided in children after 5 years of age as they are challenging to perform in older children.” However, we argue that whether an MCU is done should not be about the age but about the clinical history, the ultrasound findings, and the potential tolerance of the procedure by a well-counselled family.
An alternative to an MCU, for those who may have significant pathology, is to add a voiding phase to a MAG III study, giving an indirect radionuclide cystogram, or to investigate the child with a cystoscopy, with or without a bladder contrast study under anaesthetic.
However, we are less inclined to use the MCU in children, particularly girls with the common problem of bladder instability (the Hinman bladder with Vincent’s curtsy) who present with wetting and urgency bladder instability. A trial of more frequent voiding and anticholinergics usually resolves the bladder dysfunction, and if the ultrasound is normal, further investigation is unwarranted.
Importantly, the discussion about the role of circumcision does not mention the anatomy of the foreskin, as is the case for most studies of the role of the foreskin in infection. In fact, the 2005 article quoted by the authors states, “the risk-benefit analysis may not favour circumcision even in the higher risk populations.”
In conclusion, we urge clinicians to examine the genitalia of children with urosepsis and to perform an ultrasound on any child with a urine infection associated with a raised white cell count and to consider each patient as unique.
References:
Hinman F, Jr. Nonneurogenic neurogenic bladder (the Hinman syndrome)–15 years later. J Urol 1986; 136(4):769-777.
Vincent SA. Postural control of urinary incontinence. The curtsy sign. Lancet. 1966; 2(7464):631-632.
Singh-Grewal D, Macdessi J, Craig J. Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. Arch Dis Childhood 2005; 90: 853-858.
Authors:
Professor Paddy Dewan, MBBS BMedSc PhD MD MS MMedSc FRCS FKCS FRACS
Pediatric Urologist, Melbourne
Padma Rao, BSc Hons MBBS MRCP FRCR FRANZCR
Paediatric Radiologist, Royal Children’s Hospital, Melbourne
