One of the most common problems I see in my practice is a child who has had one or more urinary tract infections.
The most important question to ask when someone is having urinary tract infections is whether the infections happen with fever. This is referred to as a febrile UTI. The workup and management of a febrile UTI is completely different than that of a non-febrile UTI. Failing to make this distinction usually results in unnecessary radiologic testing.
A child with a febrile UTI has a temperature of more than 101.5, looks like he has the flu, and often needs to be admitted to the hospital for IV fluids due to nausea and vomiting. He may also have burning and pain with urination, but not always.
A child with a non-febrile UTI feels well overall but hurts terribly when voiding. He may also void frequently in small amounts or instead hold his urine and then have accidents. Some children may have no symptoms, though parents report a strong smell in the child’s urine.
FEBRILE UTI (UTI with fever)
Febrile UTI’s are usually due to anatomic problems like urine going backwards from the bladder to the kidneys (vesicoureteral reflux), or a blockage in the kidney, ureter, or urethra.
The American Academy of Pediatrics (AAP) recommends obtaining a renal and bladder ultrasound after the first febrile UTI mainly to rule out blockage or obstruction in the urinary tract. A renal ultrasound is well tolerated by most children, is non-invasive, and there is no risk of radiation.
After the second febrile UTI, the AAP recommends a more invasive test, disliked equally by parents and children: the voiding cystourethrogram (VCUG). The VCUG is done mainly to detect vesicoureteral reflux, a condition associated with recurrent febrile UTI’s. Surgery for vesicoureteral reflux can decrease the chances of recurrent febrile UTI’s by more than half, however, it does not affect the risk of recurrent non-febrile UTI’s.
NON-FEBRILE UTI (UTI without fever)
Non-febrile UTI’s are usually due to infrequent voiding, incomplete voiding, bad hygiene, or constipation. Children with non-febrile UTI’s usually have normal anatomy. The treatment for recurrent non-febrile UTI’s is:
voiding frequently (every 2 hours)
double voiding (the child counts to 10 after voiding and then tries to void again)
proper hygiene (sometimes using moist toilettes, wiping from front to back, etc.)
treatment of constipation (which should be continued indefinitely, usually into adulthood)
DYSFUNCTIONAL ELIMINATION SYNDROME
A small subset of children with non-febrile UTI’s have what we call dysfunctional elimination syndrome, which is a failure to relax the urinary or anal sphincters when voiding or defecating. These patients usually don’t empty their bladders completely, which results in infections and/or incontinence. They also suffer from constipation and soiling. These patients might benefit from medications or pelvic muscle training (biofeedback) when simpler maneuvers like timed voiding, double voiding, and treatment of constipation fail to solve the problem.