UTIs and Vesicoureteral Reflux
Catherine deVries MD, Pediatric Urologist
I. UTI:
- Neonate: males more than females: only age group in which true.
- Circumcision: reduces incidence of UTIs (uncirc: 11.2/1000 vs cic:
1.1/1000)
- Pyelonephritis vs Cystitis: Age group affected: if under 2 years of
age much higher incidence of pyelo with 1st infection
- Renal Scarring: best way to test: DMSA scan; ultrasound shows only
50% - the more episodes of pyelonephritis, the more likely get scarring.
II. Work-up:
Still controversial; all males with documented UTIs, all
females under age two with first UTI, anyone with pyelonephritis. Uncertain
about the 3-5 year old girl with signs and symptoms of cystitis.
Tests ordered in addition to urine culture: Ultrasound and VCUG; DMSA if
pyelonephritis is suspected.
III. Reflux: International Classification (from Pediatrics 1981; 67:392)
A. Classification
Grade I: Ureter only
Grade II: Ureter, pelvis, calyces; no dilatation, normal calyceal
fornices
Grade III: Mild or moderate dilatation and/or tortuosity of the ureter;
mild or moderate dilatation of the pelvis, but no or slight
blunting of the fornices
Grade IV: Moderate dilatation and/or tortuosity of ureter and mild
dilatation of renal pelvis and calyces; obliteration of sharp angle
of fornices
Grade V: Gross dilatation and tortuosity of ureter; gross dilatation of
renal pelvis and calyces; papillary impression s no longer visible
in calyces
B. Renal Growth and Infection: More the reflux less the renal growth, and
more the severity of urinary tract infection
C. Treatment:
1. Observation
Grades I - III: 15-17% spontaneous resolution each year. If not better
after 4 years observation, will need surgical treatment;
overall resolution without treatment:
| Grade of Reflux |
Spontaneous Resolution
(from Skoog: J of Urol
1987;138:941) |
| Grade I |
90% |
| Grade II |
80% |
| Grade III |
50% |
| Grade IV |
10% |
| Grade V |
0-10% |
2. Prophylaxis: Once a day medication (at night) to prevent recurrences;
usual length of time is 6 months to several years whether Grade I or higher.
3. Reimplantation surgery: 95% successful, but 20-40% post op UTIs: used
if recurrent pyelo, noncompliant with prophylaxis, if bladder diverticulum,
or ureteral obstruction.
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