Management of UTIs

[beru]

This sounds extreme to me:
http://www.uihealthcare.com/topics/m...ids/index.html
They recommend invasive measures after just one suspected or confirmed UTI! Both boys and girls.

We often worry about doctors catheterizing intact boys to diagnose UTIs and they recommend tests for urinary reflux after one UTI. I have always been alarmed by this and have often thought "Would they do the same for a girl or a circumcized boy?" This webpage seems to say, that yes, pediatric urologists would recommend the same for all kids. I wonder if this is really followed in real life practice.

[MCatLvrMom2A&X]

My dd got her first UTI at around 18 months and the ped. sent us straight for the VCUG and U/S. I took her because at the time didnt have internet access and had no idea what to do just had to trust the ped.

They did try to bag her to test first but after waiting several hours she didnt pee so she ended up cathed.

Ds has never had a UTI but if he does you can bet he wont be getting the VCUG after just one episode.

[tutucrazy]

Completely ridiculous! How much do they make form a VCUG?

[vulturemom]

My third DD is the only child out of five whe has had a UTI (it was probably just a suspected UTI, there was protien in her urine). They gave her atibiotics and had her come back a week (or two weeks can't remember) for another UA. That is all. No cateter, nothing else.

Mind you she was 8 so they could just give her a cup and tell her to pee so that could have made a difference.

[Frootloop]

Yes, they do this with many girls, as well My DD was one of them. She had a fever around the age of 6 weeks and since there were no other obvious signs of infection, they believed it to be a UTI. Since I had ZERO information about things like this at that point, I allowed them to cath her to get a sample (I didn't know of any other options). Turns out, she did have a raging UTI and was put on antibiotics. Even though this was her first (and only) UTI, she was immediately sent to a pediatric urologist in Nashville, which was 2.5 hours away for a VCUG. And as it turned out, she did have a grade 2 reflux (pretty mild). She was put on antibiotics for a year and with EVERY fever she had, even if it was obvious that it was from a virus (snotty nose, coughing, etc) I had to bring her in for a cath (again, I didn't know there were other options) just in case she had a UTI that was SURE to instantly damage her kidneys because of the reflux issue . She was cathed probably 6+ times before she was a year old. No other test came back positive for a UTI (not like I expected them to). After that year, she was taken off the antibiotics, which in retrospect seemed ridiculous to have her on in the first place.

For the record, even after knowing that DD did in fact have a kidney reflux, I'm still not one to recommend that our kids are immediately sent for the VCUG. It's so very invasive!!! DD is now 12 yrs old and has never had another UTI since she was 6 weeks old.

[LittleRockstar]

Originally Posted by tutucrazy

Completely ridiculous! How much do they make form a VCUG?

My dd's just had this done in Feb at 9mo after one UTI. The total was $2,187.00, not including the initial dr. visit and lab work. The breakdown went like this:

TR-INJ Procedure Cytsography $643
Cysto 250mg HOCM 17% IOD $500
ULSO-Retropertioneal - aort/re $686
Urethrocystography, voiding ... $358

So, yeah, they're making money. My intuition was telling my she was fine (and she is), but damn they put the pressure and scare tactics on!!! I'm still mad at myself for giving in.

[serendipity22]

Is a pity the US does not a public health insurance system like the UK, so there is less reward for over-servicing.

I'm sure ric would be lower if that was the case.

[workjw]

My opinion probably won't be very popular in this forum, but I'm thankful every day that they tested dd after her first UTI. We discovered that she has the highest grade reflux in both of her ureters and also has 2 additional ureters that also have reflux. She has been cath'ed over 70+ times in the last 2 years, has had 3 surgeries, 8 kidney infections and major complications from kidney reflux.

Because we had the VCUG, and discovered her condition early, we were able to take her in for a cath and urine culture at the first sign of fever. We believe (along w/ her docs) that early treatment of infections has been the main factor in preserving her kidney function. She now has a vesicostomy in place to help keep her kidneys healthy. I know many parents of children who are awaiting kidney transplants due to damage of the kidneys from "simple" urinary tract infections.

The reason most urologists insist on cath'ing is because their is a much greater risk of contamination when doing a bagged specimen. A false positive may mean a 10 day course of uneeded abx and possible further testing that was never even needed. Too be honest, in my extensive research of VUR, this is 1 of only 2 articles I've read that even mention circ and make any type of exception for cath'ing. This is actually a pretty conservative article when it comes to VUR info, imo.

My personal experience is with my daughter, but hope that I would have taken the same measures with my son. Most urologists are experienced with both circ'ed and uncirc'ed children, and if I were in the situation with ds, I would be sure that the nurses doing the procedure were experienced in cath'ing an uncirc'ed boy, and then I would have the procedure.

I'm thankful that for most children (80% or better) reflux is mild and corrects itself before the age of 7. But for many children, early testing can mean the difference between healthy kidneys and renal failure, so I'm glad it's there. FWIW dd is on state insurance, and we often have to fight for any testing, so I can't imagine it is JUST a money making issue since it's considered standard procedure.

Didn't mean to get on my soap box, I just feel pretty strongly about this issue.

[tutucrazy]

Originally Posted by workjw

My opinion probably won't be very popular in this forum, but I'm thankful every day that they tested dd after her first UTI. We discovered that she has the highest grade reflux in both of her ureters and also has 2 additional ureters that also have reflux. She has been cath'ed over 70+ times in the last 2 years, has had 3 surgeries, 8 kidney infections and major complications from kidney reflux.

Because we had the VCUG, and discovered her condition early, we were able to take her in for a cath and urine culture at the first sign of fever. We believe (along w/ her docs) that early treatment of infections has been the main factor in preserving her kidney function. She now has a vesicostomy in place to help keep her kidneys healthy. I know many parents of children who are awaiting kidney transplants due to damage of the kidneys from "simple" urinary tract infections.

The reason most urologists insist on cath'ing is because their is a much greater risk of contamination when doing a bagged specimen. A false positive may mean a 10 day course of uneeded abx and possible further testing that was never even needed. Too be honest, in my extensive research of VUR, this is 1 of only 2 articles I've read that even mention circ and make any type of exception for cath'ing. This is actually a pretty conservative article when it comes to VUR info, imo.

My personal experience is with my daughter, but hope that I would have taken the same measures with my son. Most urologists are experienced with both circ'ed and uncirc'ed children, and if I were in the situation with ds, I would be sure that the nurses doing the procedure were experienced in cath'ing an uncirc'ed boy, and then I would have the procedure.

I'm thankful that for most children (80% or better) reflux is mild and corrects itself before the age of 7. But for many children, early testing can mean the difference between healthy kidneys and renal failure, so I'm glad it's there. FWIW dd is on state insurance, and we often have to fight for any testing, so I can't imagine it is JUST a money making issue since it's considered standard procedure.

Didn't mean to get on my soap box, I just feel pretty strongly about this issue.

But would it have been terrible to wait for a 2nd UTI before doing the test. You still would have caught it early before there was damage to her kidneys, right?

How common are these severe cases of reflux?

How accurate are these VUCGs? Could it appear as more severe than it really is?

Just a few thoughts...

[kateygirl76]

Both of my twin boys had UTIs that spread to their kidneys. Kevin was 6 weeks old and spiked a fever of 105 and Patrick was 9 weeks old. Kevin was extremely ill. Both were hospitalized for 3 days and yes, both were cathed for urine specimens and both had a VCUG. Personally I do not want them to get that sick again so knowing whether or not they had reflex was important. The doctors were great doing the VCUGs, did not retract at all, did not make any comments about circumcision. And surprisingly, they were not that upset by it. Neither of my boys have reflux but the studies I read said up to 50% of kids that develop UTIs have it so for me it was worth the piece of mind.

[MyBoysBlue]

Can you point us to the study that says

studies I read said up to 50% of kids that develop UTIs have it

I would be interested in reading it.

[workjw]

Sorry, I should have clarified a little. I don't necessarily think all children with UTI need further evaluation. I was referring more to the article and agreeing that children under the age of 2, with a high fever and no other symptoms should be evaluated for UTI. The UTI is not the problem, it's the fever in addition to the UTI that is concerning. A fever is a big red flag that the infection has moved into the kidneys where it causes damage.

Originally Posted by tutucrazy

But would it have been terrible to wait for a 2nd UTI before doing the test. You still would have caught it early before there was damage to her kidneys, right?

Not necessarily. I agree that in most cases, you may be fine to wait until the second UTI (especially if it was a UTI with no fever), but for us it made a significant difference b/c we treated her so much sooner. I think many of us on here would treat a 6 mos old with fever at home for a few days before seeing a physician. Then you wait 2-3 days for a urine culture (assuming they take a urine sample) before treating with abx. That would mean an infection in the kidneys for almost a week before treatment. That puts a child with reflux (at any grade) at significant risk of renal damage, especially in a child under a year.

Originally Posted by tutucrazy

How accurate are these VUCGs? Could it appear as more severe than it really is?

I think a VCUG is pretty accurate, especially when done through 2 voiding cycles. I have (personally) never heard of a VCUG showing reflux as more severe, only not showing it if it was present.

Originally Posted by tutucrazy

How common are these severe cases of reflux?

Most researchers say that 1-3% of the population has VUR. 80% or so resolve over time, and the other 20% require surgery to correct it. It is extremely rare to have as many complications as dd, but kidney damage is not uncommon in children with reflux.

[workjw]

Originally Posted by MyBoysBlue

Can you point us to the study that says



I would be interested in reading it.

I know this question wasn't for me, so hope you don't mind me responding.

http://emedicine.medscape.com/article/414836-overview

This one breaks it way down, and 50% is the high end for symptomatic UTI. On average most studies (including the one above) show b/w 30-40% of children presenting with UTI have VUR.

HTH

[MyBoysBlue]

I guess the quote wasn't specific. Not just kids who have 1 UTI. UTI's are so common it just didn't make sense to me that 50% would have reflux.

Up to 50% of children with proven UTI undergoing VCUG have some degree of reflux.

So 50% of children undergoing VCUG. Not of all kids who have a UTI. Because a little girl of 3 who has one UTI will in all likelihood not under go a VCUG. That makes more sense.

[tutucrazy]

Originally Posted by workjw

Most researchers say that 1-3% of the population has VUR. 80% or so resolve over time, and the other 20% require surgery to correct it. It is extremely rare to have as many complications as dd, but kidney damage is not uncommon in children with reflux.

This is enough for me to say, "monitor the situation". If your child has a mild UTI I would not jump to do a VCUG. Maybe a very high fever in a young infant with UTI, but not for older babies and children.

[kateygirl76]

kidshealth.org, article was given to me at hospital - this one says up to 50% with a UTI, not that undergo a VCUG

Related Conditions Associated With Recurrent UTIs
Recurrent UTIs are sometimes seen in conjunction with other conditions, such as:

vesico-ureteral reflux (VUR), which is found in 30%-50% of kids diagnosed with a UTI and is a congenital (present at birth) condition in which urine flows backward from the bladder to the ureters (the thin, tube-like structures that carry urine from the kidney to the bladder) and sometimes reaches the kidneys. If the urine in the bladder is infected with bacteria, VUR can lead to pyelonephritis.