Urinary Tract Infection

Signs and Symptoms

The urinary tract consists of the kidneys, ureters, bladder and urethra. The kidneys filter waste from blood to produce urine. Urine travels from the kidneys down the ureters and into the bladder. Urine is stored in the bladder until urination occurs. The tube that urine passes through during urination is called the urethra.

A urinary tract infection is an inflammation of the bladder or the bladder and kidneys. It usually is caused by bacteria from the skin outside the urethra, moving up the urethra and into the bladder. If the bacteria stay in the bladder, the infection is called cystitis. If the bacteria are in the kidneys, it is called pyelonephritis. These infections are not contagious.

The signs and symptoms of urinary tract infections in children depend on the child's age, and may include any or all of the following:

Infants

• Fever
• Irritability
• Inconsolable
• Vomiting and diarrhea
• Loss of appetite
• Failure to gain weight

Since these are generalized symptoms in most infants, the diagnosis of urinary tract infection may be overlooked.

Older Children

• Burning or pain with urination
• Frequent or urgent urination
• Fever
• Lower abdominal pain
• New wetting episodes or more frequent occurrences
• Side or back pain
• Blood in urine

As children reach toddler age, more classic symptoms appear, such as painful urination, urinary frequency and urgency. It becomes easier to recognize urinary tract infections as your child becomes verbal and is toilet-trained.

Sometimes the symptoms result from or can be aggravated by other causes of urethral irritation, such as bubble baths, poor hygiene or constipation.

Regardless of age, bladder infection isn't usually associated with fever, and generally doesn't produce any long-term damage to the bladder or kidneys.

However, kidney infection usually is associated with a high fever and may produce permanent damage or scarring of the kidney even after only one infection. This is particularly true in very young children.

Diagnosis

We first talk with your child and yourself about her or his health in general and then about symptoms. We will perform a urinalysis, which involves looking at your child's urine with a microscope. To be certain that there is an infection, we also will do a urine culture to see if bacteria from the urine will grow in a culture medium. Your doctor will have the results of the urine culture after 24 hours. If infection is present, an additional 24 hours usually is necessary to find out which antibiotic will kill all of the bacteria.

The method of urine collection will affect the accuracy of the urine culture. It is important to:

• Wash the skin around the urethra with a cleaning pad to remove bacteria on the skin surface.
• If urine is collected at home, place the urine sample in the refrigerator and then pack it in ice while traveling to the doctor's office.

To collect urine from infants and toddlers, a special bag is placed over the genital area to collect urine. Because bacteria from the skin may contaminate these samples, it sometimes is necessary to insert a small plastic tube called a catheter through the urethra into the bladder to obtain a clean specimen.

Children who have confirmed urinary tract infections should have an X-ray evaluation. This is especially important for infants and toddlers, since most of them will develop another urinary tract infection later. Waiting until a child has had two or more urinary tract infections before X-ray evaluation increases the risk of permanent kidney damage or scarring. Abnormalities of the urinary tract occur in 25 percent to 50 percent of children with documented urinary tract infection.

We also test for vesicoureteral reflux, the abnormal back flow of urine from the bladder into the ureter and up to the kidney. Reflux is dangerous because it allows bacteria that might be in the bladder to reach the kidney. This can cause a kidney infection and lead to kidney damage.

Here are some of the basic tests we may suggest if your child has a urinary tract infection:

• Voiding Cystourethrogram (VCUG) -- This test gives us important information about the shape and size of the bladder, the bladder neck or opening and the tubes, called ureters that drain the urine from the kidneys into the bladder.

  A small plastic tube is inserted into the urethra so that a fluid called contrast media can flow into the bladder. While your child's bladder is filling, he or she can watch a video. We encourage children to bring along their favorite one, and we always have a few others, like The Lion King, on hand. Pictures are taken while your child's bladder is filling. When your child's bladder is full, we remove the catheter and take a picture as he or she urinates. After the study is done, we will review the films with you and your child. Together we will discuss a plan of care.

  This procedure is not painful per se, but some discomfort may occur when the tube is placed. Most of all, the experience may be perceived by your child as scary and certainly unusual. Your child will take his or her cues from you, feeling more comfortable if you are. It is most important that at least one parent remain with your child in the room at all times. We will explain everything as we go. The more detailed literature will discuss strategies to help minimize your child's anxiety during this study. The test usually takes 20 to 30 minutes.

• Kidney and Bladder Sonogram (Ultrasound) -- Otherwise known as "jelly-on-the-belly." This test is done to outline the kidneys, ureters and bladder. It looks for additional urinary tract defects that could be the cause of infection. The test doesn't require radiation and is painless.

• Kidney (Renal) Scan -- This test may be done if the above tests are abnormal. It is used to better demonstrate the actual function and drainage of the kidneys. A kidney scan also can show if there is kidney damage and scarring.

Treatment

All children with urinary tract infections are treated with a safe and well-tolerated antibiotic selected to treat the specific bacteria identified by the urine culture. Children with a bladder infection usually are treated with a seven-day course of medication. Children with kidney infections should be treated for 10 to 14 days. A child who is very ill or who has a kidney infection most likely will require hospitalization for intravenous antibiotics until the fever subsides and the urine culture results are known.

• Another urine culture will be done while your child is taking the antibiotic or when the medication is finished to make sure the infection is gone.

• If your child has not had an X-ray evaluation, the antibiotics should be continued until the appropriate X-rays are done and our office has instructed you that it is safe to stop the antibiotics.

• Children with urinary infections may have unhealthy urination habits. Establishing a schedule and completely emptying the bladder every two to three hours often helps. This problem usually disappears as the child enters puberty. If no kidney damage is present at the time of initial evaluation, these children are not at greater risk for serious problems in the future.

• Some children who have repeated urinary tract infections for no obvious reason may require continuous low-dose medication for a period of time.

• Stretching the urethra (urethral dilation) isn't a technique our urology team uses. In the past, it was believed that many girls who got urinary tract infections had narrow or tight urethras. We now know that the size of the urethra is no different between girls who have infections and those who don't.

• Treatment for vesicouretal reflux will vary according to the child's age, number of urinary tract infections and test findings.