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Dr MJ EngelbrechtDept Urology
University of Pretoria
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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
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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
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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
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Abnormalities found (50% of children) VUR
85% of urinary tract abnormalities Obstruction
Posterior urethral valves PUJ Obstruction Primary obstructive megaureter Ureterocele
Other Neurogenic bladder Calculi
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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.
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Primary reflux Short submucosal tunnel
Secondary reflux N - Neurogenic bladder O - Obstruction T - Trauma or surgery I - Infection C - Congenital ureteric abnormalities E - Ectopic ureteric openings
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1-2 % of children 20 – 30 % of
children with UTI Outosomal
dominant genetic disorder 30% in siblings 50% in offsprings
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Reflux nephropathy Hypertension Chronic renal failure
20% of pediatric renal transplant patients have reflux nephropathy
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VCUG “gold” standard Done after the UTI has been treated Advantages
Grades reflux Excludes secondary
causes of reflux
Indirect nuclear cystography
Ultrasound
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VCUG
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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
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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)
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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 -Stone or
blood clot In the wall - Stricture
from
infection or trauma
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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
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Ultasound First investigation Will show
hydronehrosis with normal ureter
IVP Show dilated renal
pelvis with normal ureter
MAG 3 renogram
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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
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Surgical Open surgical
Pyeloplasty Endoscopic
Endopyelotomy Balloon dilatation
Laparoscopic Nephrectomy
If non fuctioning kidney
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Thin membrane obstructing the urethra distal to the verumontanum
This cause proximal urethral dilatation, severe bladder trabeculation and bilateral hydronephrosis
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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
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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
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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)
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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