Uti in an infant?

[lovingthis]

We kept our second son intact, despite the criticism from pretty much everyone we know ( and now the AAP...) . We didn't have the same knowledge when our first son was born 9 years ago, we did allow him to be circumcised. I do regret that, but I also know that I was doing the best I could with the information I had available...hope that my son will understand that as well ( so far he hasn't seemed to notice that there is anything different about his baby brother during diaper changes.
Anyhow...long winded way of saying that I am new to caring for an intact boy and am now really worried that after all of the time I have had to spend justifying our decision with people and arguing about "cleanliness" my poor four months old might have a Uti.
So today after 3 days of fever, it struck me to collect a urine sample when he got up from a nap (we do a kind of modified ec with him) . There was much less than normal and much darker, and it was heavy with leukocytes, but no nitrates. So I am kind of confused whether that is a good indication for uti, or just tell tale for a little guy who has been feverish and eating less than normal. I am nervous to take him in because I know that our doctors clinic likes to rx antibiotics even when there isn't an infection ( they tried to get me to take them when I was pg even though all cultures were negative.....turned out to be kidney stones instead....)
Has anyone ever dealt with a uti in a little guy too small to tell you what hurt? What were the symptoms like? Thank you in advance.
I tried to give him some homemade pedialyte with a touch of gse just in case.....but fellow is just NOT into taking a bottle.
* we do not retract his foreskin, and I was hoping that would protect him..

[MCatLvrMom2A&X]

The only way to know for sure if it is a UTI is to take the sample in and have them test it. If it is a UTI then he does need abx and if it comes back again then he should have the VCUG test which checks for urinary abnormalities, UTI has nothing to do with having a foreskin so no need to worry about that.

If it isnt a UTI then you can refuse abx. or take the script and not get it filled.

[lovingthis]

Thanks. I have just been flustered by all of these studies saying that intact boys are so much more likely to get uti. I still don't think that's enough reason to remove a body part....but it certainly hurts my case with everyone who has been telling us that it is "dirty ". At this point, I am thinking that a primary illness led to low Heine output, which allowed a uti...not that it has been a uti all along - hubs reminded me that he was hoarse the first evening of the fever just as my older son is now.
I usually just refuse abs tor myself in that case, but my bigger concern was that they would simply order abs without trying to get to the bottom of what it really was.
Would you mind to explain the VCUG...so I could be prepared to counter them with that if indeed the culture shows no growth ( my sub. Tests still show leukocytes but no nitrates, even first in AM sample) . I have had this jiggling feeling that something isn't ok with him even before these symptoms, but l just keep figuring that is paranoia/ extra protective feelings over him because even though he is my fourth, he is the only one who had any kind of birth trauma..making me almost feel like my first all over again...nervous and unsure.....but that ttauma was also what gave us the courage to ignore our families and keep him intact....he extra lush to tell us the poor little boy didn't deserve any kind of preventable pain. Thank you so much.

[lovingthis]

Thank goodness...we managed to get a wonderful doctor today. She really listened to me and sent us home with some collection bags so that we didn't have to wait there and /or cath him. She was nothing but supportive about him being intact...kind of looked scornful about the AAP change in stance...
hank you so much.

[MCatLvrMom2A&X]

I am so glad you got a good Dr. they can be really hard to come by.

The VCUG is where they place a catheter into the bladder then fill it with die and see if it refluxes back into the kidneys if it does then there is an abnormality and usually they put a child on abx long term to keep infections under control. Since untreated infections eventually lead to kidney damage.

My dd had it done at 18 months and it was a bit traumatic because they have to hold them down and based on my own experiences with a cath. it is painful to a certain extent.

[Espion]

How old is your son?  

2 things:  

1.  The risk of UTI in un-circ'd infants is 20 times higher until they are one year of age.  After that it drops dramatically (hence, not necessarily a reason to circumcise your son).  Beware of bag collection urine samples in uncircumcised infants too, though.  Sometimes it can be difficult to tell the difference between contamination and a real infection.  One would be ignored and the other treated. 

2.  A Voiding Cystourethrogram is a test to evaluate for vesicoureteral reflux.  Essentially the urine is going the wrong way down a one-way street.  This can be dangerous with multiple UTIs, because infected urine can yo-yo back up to the kidney and cause damage.  

That being said, it is not common, and in most (not all) children it will spontaneously resolve.  The AAP guidelines now usually recommend a 2nd febrile UTI before getting that study if you are between the ages of 2 months and 2 years.  

It does require a catheter inserted in the urethra to the bladder, and I have never heard a parent say that they "don't mind" the study.  The catheter is really the only worst part, but that can be more than enough.

The test wouldn't exist if it wasn't important for some children, but the challenge is to identify who those children are without subjecting them all to a bad experience.  

My opinions are my own, but they come with a background of $170,000 worth of debt.  I am not an "inactivist" (although it is nice to educate myself on other people's views) but I tell parents regularly that I wouldn't recommend circumcision unless their child has a potentially devastating kidney issue.  Sometimes a few UTIs are all that is needed to break that straw, and kidneys are worth more than foreskin.  

[Espion]

Let me edit to add, that on re-read, what I'm saying can sound a little frightening.  Please take it as just explaining based on raw and limited information, because there is no way for me to tell what is going on based on a few sentences, and honestly, I'm not going to open that can of worms on a forum.  I'm here because I'm gestating a squeaker and I fell in this forum because I think that the opinions are engaging and germane to my job.  :)

[mama24-7]

Originally Posted by Espion 

How old is your son?  

2 things:  

1.  The risk of UTI in un-circ'd infants is 20 times higher until they are one year of age.  After that it drops dramatically (hence, not necessarily a reason to circumcise your son).  Beware of bag collection urine samples in uncircumcised infants too, though.  Sometimes it can be difficult to tell the difference between contamination and a real infection.  One would be ignored and the other treated. 

Would you please tell us the basis for this?  The only study that I am aware of on UTIs in boys was done on premature boys.  Is this a study that was done in a country that does not routinely circumcise?  I wonder what the UTI rate of baby boys is in Europe?

Quote:

Originally Posted by Espion 
2.  A Voiding Cystourethrogram is a test to evaluate for vesicoureteral reflux.  Essentially the urine is going the wrong way down a one-way street.  This can be dangerous with multiple UTIs, because infected urine can yo-yo back up to the kidney and cause damage.  

That being said, it is not common, and in most (not all) children it will spontaneously resolve.  The AAP guidelines now usually recommend a 2nd febrile UTI before getting that study if you are between the ages of 2 months and 2 years.  

It does require a catheter inserted in the urethra to the bladder, and I have never heard a parent say that they "don't mind" the study.  The catheter is really the only worst part, but that can be more than enough.

The test wouldn't exist if it wasn't important for some children, but the challenge is to identify who those children are without subjecting them all to a bad experience.  

Isn't there another step between multiple (which from what you are saying, would be two or more)?  My niece had reflux of the bladder & I thought I remembered there being another step.  But, I could be remembering wrong.

Quote:

Originally Posted by Espion 
My opinions are my own, but they come with a background of $170,000 worth of debt.  I am not an "inactivist" (although it is nice to educate myself on other people's views) but I tell parents regularly that I wouldn't recommend circumcision unless their child has a potentially devastating kidney issue.  Sometimes a few UTIs are all that is needed to break that straw, and kidneys are worth more than foreskin.  

Out of curiosity, are you a doctor?  Did you take the hippocratic oath?  Why would you recommend an external body part for an internal problem?  What would be your recommendation for a female child who routinely had UTIs?  Do you perform circumcisions on consenting individuals?  How about non-consenting individuals?  

It is nice to have medical professionals here, even if they are not an "inactivist."  (Actually, I consider myself a humanist - one who believes in each persons right to their whole body, regardless of any ideas, beliefs, ignorances (is this a word? not sure ), biases, etc. that a parent may have.) 

Thanks for answering my questions. 

Sus

[Espion]

Originally Posted by mama24-7 

Would you please tell us the basis for this?  The only study that I am aware of on UTIs in boys was done on premature boys.  Is this a study that was done in a country that does not routinely circumcise?  I wonder what the UTI rate of baby boys is in Europe?

Isn't there another step between multiple (which from what you are saying, would be two or more)?  My niece had reflux of the bladder & I thought I remembered there being another step.  But, I could be remembering wrong.

Out of curiosity, are you a doctor?  Did you take the hippocratic oath?  Why would you recommend an external body part for an internal problem?  What would be your recommendation for a female child who routinely had UTIs?  Do you perform circumcisions on consenting individuals?  How about non-consenting individuals?  

It is nice to have medical professionals here, even if they are not an "inactivist."  (Actually, I consider myself a humanist - one who believes in each persons right to their whole body, regardless of any ideas, beliefs, ignorances (is this a word? not sure ), biases, etc. that a parent may have.) 

Thanks for answering my questions. 

Sus

I wish I could do the fancy quote thing!

Here is a meta-analysis (the best possible assimilation of research if done properly).  The underlining is mine:

[I'm editing the abstract to quote from the source for copywrite infringement concerns.  You can utilize information for purposes of "Research and Study", but it's late and I'm not interested in breaking any laws.  :)] ]

Source is from the Arch Dis Child. 2005 Aug;90(8):853-8.  [You should be able to look this journal up in a medical or university library.]

Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies. 

Singh-Grewal D, Macdessi J, Craig J

 

This is a meta-analysis to analyze the circumcision and the risk of UTI.   "Data on 402,908 children were identified from 12 studies (one randomised controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with a significantly reduced risk of UTI (OR = 0.13; 95% CI, 0.08 to 0.20; p<0.001) with the same odds ratio (0.13) for all three types of study design."

Conclusions:  "Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to-treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively. Haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%. Assuming equal utility of benefits and harms, net clinical benefit is likely only in boys at high risk of UTI." 

One hundred and eleven circs to prevent one UTI.  That's why I don't recommend it or push it.  The fact is that it is an American "aesthetic".  Outside of the United States, the vast majority of circumcisions are done for religious reasons.  We are the only ones that do it because many Americans think it "looks good" or "because their fathers were", etc.

Reflux really requires looking at the entire clinical picture.  Little girls have a lot of reasons for UTIs, and while reflux is one of them, it is not the most common.  I would work on toileting, making sure they are not constipated, etc. before pursuing a VCUG.  You can get an ultrasound that may or may not show dilation in the renal collecting system (hydronephrosis), but that has never been shown to correlate to the degree of reflux.  Another alternative is to get a nuclear medicine study, but that requires an IV.  The AAP guidelines regarding reflux are new and part of the intention is to prevent reflex ordering of the VCUG after a febrile UTI.

Yes I am and yes I did.  In fact I have the job that is mentioned in the Hippocratic oath.  :)   I tell you when I do recommend circumcision, is when I see a male infant with posterior urethral valves.  It is rare, but anything that can hurt kidneys that may already be frail can be potentially devastating.  (A baby on dialysis is a terrible sight.)  That being said, I'm also willing to closely follow a family through the first couple of years if they don't want one.

Information is power, I've always felt that it is up to the patient to determine what is best for them and it is my job to provide information that can be understood and processed.  (I'm the queen of analogies.)  But taking care of kids is tough.  Surrogate decision making that parents make for their children is a controversial and much debated topic in medicine (and, believe it or not, part of the political platforms).  Which is why the concept of assent is also very, very important.  

And my full disclosure is that I can't be a complete "intactivist" because I have circumcised plenty of men who have asked for it for religious and personal reasons - from teenagers to 70 year old men (because they think it will be the next best thing since sliced bread, their words, not mine!) as well as (and I know that this will make some of you angry, which is not my intent) infants for whom parents have requested it.  

A part of my job is trying to teach people (including medical-types) not to fear the foreskin!!  (This is especially problematic in nursing homes.)   

Edited by Espion - 10/6/12 at 9:03pm

[Espion]

My post has to go through a moderator because of wonky formatting (I cut/paste some stuff...that apparently shows up on their spam filters).  :/  Hopefully they will see that I'm not a meanie/troll and it will be up soon!  

[MCatLvrMom2A&X]

Removing the foreskin will not stop UTI if it did then my dh and every other circed guy wouldnt get them. Like the pp said the study was done on PREMI infants not on babies born at term so the study is by its very nature flawed.

UTI in a boy should be treated the exact same way as in a girl with no cutting involved of the genitals.

[MCatLvrMom2A&X]

Removing the foreskin will not stop UTI if it did then my dh and every other circed guy wouldnt get them. Like the pp said the study was done on PREMI infants not on babies born at term so the study is by its very nature flawed.

UTI in a boy should be treated the exact same way as in a girl with no cutting involved of the genitals.

[Espion]

Answers posted, thank you Moderator!  

With that ladies, I'm going to respectfully bow out of the discussion.  This is a hot topic and I respect the views/opinions of both sides.  I absolutely understand that I will not convince many people that circumcision is okay "some of the time".  

But now you have more than "the preemie study" to add dimension and a little more clout to the debate!  ;)  

(This is broad information that can be found anywhere on the internet and not meant to be targeted advice:  And as far as intact care, I tell moms just do what your grandma taught you.  Good old fashioned soap and water, pat dry.  Don't forcibly retract, and for pete's sake, don't let anyone forcibly retract (one) and (two) then not replace the foreskin (meaning draw it back over the glans).  Paraphimosis is not cool.  Usually 90% of children will have fully retractable foreskin by the age of 3, if not, then it's not the end of the world.  Yeast infections can occur on occasion.  Treat topically, primary concern is phimosis (narrowing of the foreskin) and recurrent skin infections.  Phimosis can be treated with topical steroids if desired after the skin infection is cleared.)    

[beru]

Originally Posted by Espion 
Usually 90% of children will have fully retractable foreskin by the age of 3, if not, then it's not the end of the world. 

I have a lot of respect for the informative posts you have made. But this statement harms your credibility a bit. Please tell me you are not a pediatric urologist who believes that 90% of boys are retractable by 3.

In the following studies, 90% of boys are not fully retractable until 11 to 15 years old!

Imamura - 38% are retractible by 3 years of age.

Kayaba - 16.5% are retractile by 3.

Oster - ~65% non-retractile at age 6 (starting age in study)

Thorvaldsen - average age of retraction in Denmark = 10.4.

Øster J. Further fate of the foreskin: incidence of

preputial adhesions, phimosis, and smegma among

Danish schoolboys. Arch Dis Child 1968;43:200-3.

Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape

and retractability of the prepuce in 603 Japanese boys. J

Urol 1996;156(5):1813-5.

Imamura E. Phimosis of infants and young children in

Japan. Acta Paediatr Jpn 1997;39(4):403-5.

Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk

fimose? Ugeskr Læger 2005;167(17):1858-62.

[Espion]

Originally Posted by beru 

I have a lot of respect for the informative posts you have made. But this statement harms your credibility a bit. Please tell me you are not a pediatric urologist who believes that 90% of boys are retractable by 3.

In the following studies, 90% of boys are not fully retractable until 11 to 15 years old!

Imamura - 38% are retractible by 3 years of age.

Kayaba - 16.5% are retractile by 3.

Oster - ~65% non-retractile at age 6 (starting age in study)

Thorvaldsen - average age of retraction in Denmark = 10.4.

Øster J. Further fate of the foreskin: incidence of

preputial adhesions, phimosis, and smegma among

Danish schoolboys. Arch Dis Child 1968;43:200-3.

Kayaba H, Tamura H, Kitajima S, et al. Analysis of shape

and retractability of the prepuce in 603 Japanese boys. J

Urol 1996;156(5):1813-5.

Imamura E. Phimosis of infants and young children in

Japan. Acta Paediatr Jpn 1997;39(4):403-5.

Thorvaldsen MA, Meyhoff H. Patologisk eller fysiologisk

fimose? Ugeskr Læger 2005;167(17):1858-62.

It's personal (i.e. anecdotal) experience.  :)  Again we don't force it and advise only gentle hygiene.  Thank you for the info though, sometimes "give it time" can be a hard thing to hear.  

[Storm Bride]

Originally Posted by Espion 

And my full disclosure is that I can't be a complete "intactivist" because I have circumcised plenty of men who have asked for it for religious and personal reasons - from teenagers to 70 year old men (because they think it will be the next best thing since sliced bread, their words, not mine!)...

This part has nothing at all to do with being, or not being, an intactivist. I'm in contact regularly (online) with at least dozens, probably hundreds, of intactivists. I have yet to meet or talk to a single one who has an issue with men requesting circumcision for themselves...not one. Teenagers are a little more complicated, as cosmetic surgery on teens is an iffy area - I personally don't think people in their teens should be making permanent changes to their bodies, because they may change their minds drastically once they're out of the peer pressure crap. In any case, I don't think that's going to happen much as the circ rate for infants drops.

What intactivists object to is routine infant circumcision. I don't believe it should be legal, actually. But, I really don't care if grown men want to cut off their own body parts.

[gonyere]

My DS2 had a UTI at ~2wks old... it was scary as can be, especially at that age cause' they really have *NO* idea why they are having a fever. DS2 had the whole workup - spinal tap and all. We then did go a head and have the VCUG done just to check. His came back negative, and he's never had another. At the time we had good insurance and so getting the VCUG done made sense, especially since we knew we were going to loose it shortly (for all intents and purposes we dont have insurance today - w/ deductibles of 5k in-network and 7.5k out-of-network, we still avoid doctors for obvious reasons!!)