Urinary Tract Infections in Children

Scott Berkman, MD, a Pediatric Urologist with Saint Francis Children’s Physicians, answers questions about urinary tract infections in children.

Q: What is a urinary tract infection (UTI), and what are the common causes?

Dr. Berkman: Urinary tract infections can be viral, bacterial or parasitic. Today, we’re just going to talk about bacterial infections. The urinary tract starts at the kidney. Urine is made in the kidney; the urine travels down the ureter, the tube from kidney to bladder, and ends up in the bladder before you empty. So anywhere along that path is a urinary tract infection, from kidney to the outside.

For the most part, starting at birth, boys are more commonly getting the infections in the first year of life. Uncircumcised boys have a higher incidence of urinary tract infections in their first three months of life. Also, the pressures that are required to empty their bladder are higher in their first year of life, so boys frequently can get infections at that age.

Girls have infections earlier in their life because their urethra is shorter, and the bacteria have an easier time making it into the urinary tract. Girls will then become the more commonly affected gender after about a year of age. A urinary tract bacterial infection can be from a female wiping from back to front, carrying some of the bacterial flora to the urethra.

Dysfunctional voiding when they’re learning to toilet train causes both boys and girls to have the same incidence of infection.

Sometimes, urinary tract infections come from anatomical abnormalities of the urinary tract, which can lead to stagnant urine and infections.

Q: What are some of the symptoms that parents should watch for in their children, and when should they call a doctor?

Dr. Berkman: You can separate urinary tract infections to upper urinary tract infections and lower urinary tract infections. Lower urinary tract infections involve the bladder to the outside. Those mostly present with dysuria, or burning with urination; urinary urgency or frequency, needing to go to the bathroom frequently; urinary incontinence, leaking urine; and/or blood in the urine.

An upper urinary tract infection is above the bladder. These often present with flank pain, or pain in the side or the abdomen, with fever, nausea and vomiting.  If those symptoms occur, an investigation of the urinary tract with a urinalysis and some imaging would be reasonable.

Infants often will present with fever before parents know — it’s hard to pick up that they’re having burning or frequency/urgency urinating while they’re still in diapers and not talking. I would say that infants present mostly with fever. Watch for signs of discomfort such as grimacing. Once they’re able to talk, they can tell you they’re in pain So, if the baby has fever and there’s no other obvious source, then the urine should be evaluated by a physician during the fever workup.

Once they’re talking and can tell you their symptoms, I would suggest calling a doctor and probably getting a urinalysis.

Q: Is there anything parents can do to prevent UTIs?

Dr. Berkman: For little girls, we always say, no bubble baths. It can alter the natural defense mechanisms of the urethra, allowing bacteria to get in. Also, wiping front to back to not carry the bacteria front toward the urethra.

And then, elimination dysfunction creates a high risk for infection, so make sure kids are emptying their bladders, and that they’re not constipated. Those can cause urinary tract infections.

If they have recurrent infections, having a radiographic evaluation, getting x-rays and seeing one of us to make sure there’s no anatomic abnormalities on the inside that predispose them to infections would be helpful.

Q: Do children always need to see a health care professional when they have a UTI, and how would they be diagnosed?

Dr. Berkman: If they have symptoms of urinary tract infection, then a urinalysis is indicated. A child that’s not toilet trained usually requires a catheter to be placed into the bladder. Or they may have a super-pubic aspiration, where the doctor goes directly into the bladder through the abdomen to get a sterile urine sample.

Sometimes, if a bag specimen is obtained, where they just put a bag over the urethra, it can be contaminated and then confused as an infection. The only time the bag specimen is really helpful is if it’s perfectly clear, then you could say there’s no need for the catheter and the urine looks good. But often, it can be contaminated, so that’s a challenge.

If a child is very sick with fever, you’d probably want a catharized specimen to get a good initial sample because once you give antibiotics, the results of the urine sample will be skewed.

So, the first step is getting urinalysis. If there is a sign of pus or pyuria or bacteria, then a urine culture is sent to the lab. You can then treat the infection with culture-specific antibiotics once the lab tells you what is growing.

Q: Does the child’s pediatrician do those things, or is the child referred to someone like you, a specialist, to do that?

Dr. Berkman: Usually, the pediatrician will do that. Some will obtain the urinalysis, find the urine sample has either pyuria or bacteriuria, find that there’s some bacteria growing and then be able to treat that.

If the patient gets admitted to the hospital, then we will often do a radiographic workup. If they’re having recurrent hospital admissions for infections, then we’ll need to get further evaluation.

As a pediatric urologist, I usually get involved if the infection is recurring, or if the child is so sick that they are admitted to the hospital.

Q: These infections can be serious, with a child being admitted to the hospital.  What is a recurrent UTI, and why do some children have them?

Dr. Berkman: A recurrent urinary tract infection would be two lower urinary tract infections within six months, or three within a year. So, if a child is having recurrent symptoms – burning, urgency, blood – and then the doctor keeps finding bacteria, and you see that two or three times a year, that would be recurrent urinary tract infections. They shouldn’t be having that many.

If you have one with fever, that raises your sense of awareness: Should we be evaluating the urinary tract? The new data says you could give them one chance to have a febrile urinary tract infection, where a urinary tract infection is associated with a febrile illness. Now it’s going to move to two. But it depends on how sick the child gets, and how interested somebody is in pursuing a radiographic workup.

If the child does end up with a fever associated with the infection, it usually indicates an upper urinary tract infection, which involves the kidney. That becomes an issue that really should require further treatment and care.

With fever, children often have difficulty tolerating anything by mouth. If they can’t take oral antibiotic therapy, they’re going to need to be admitted to the hospital for IV antibiotic therapy.

Recurrent urinary infections for the lower urinary tract would be three or four infections a year. We’d still want to work that up.  With one febrile urinary tract infection, you could start with an ultrasound, but to do a catheter study to evaluate for another condition called vesicoureteral reflux, where urine regurgitates back up in the kidney, we usually wait for the second febrile urinary tract infection. But if there’s significant findings on an ultrasound or if the kids are really getting that sick, then we might intervene more quickly.

Q: Are there other treatments besides antibiotics?

Dr. Berkman: If they’ve had recurrent urinary tract infections, then we would start with a non-invasive renal ultrasound study to look at the child’s renal anatomy to see if there is any hydronephrosis, or fluid in the kidney. Is there any evidence of scarring of the kidney? Are they the right size, or are they in the right location?

That would lead you toward another study called a VCUG, or voiding cystourethrogram, where you put a catheter in the bladder, fill it up with a liquid that shows up on x-ray, see if it regurgitates into the kidney, to define whether they have reflux into the kidney. You usually watch and see if that can resolve spontaneously over time or it could  require surgical intervention.

If there’s fluid in the kidney, then sometimes, if it’s of a significant degree, we’ll have a third study called a renal scan to determine the function of the kidney.  If there are anatomic abnormalities, there’s more to do. But initially, antibiotics are prescribed to take care of the infection.

If a child can take things by mouth and they’re not having nausea and vomiting, oral antibiotics are prescribed. If they’re not taking anything by mouth and they’re very sick, they go to the hospital for intravenous antibiotics.

If they have some anatomic abnormalities, sometimes they’ll need surgical intervention. I’m just a human plumber, so if they need that, then I’m happy to fix those things. If there’s reflux, I basically move the tube into the bladder and create a bigger tunnel so that the reflux does not occur. If there’s an obstructive part of the urinary tract, then the surgery involves taking out the obstruction to allow the urine to flow properly. That usually takes care of their pain and recurrent infections. I follow up with them to make sure everything does well.

Our main goal is to keep the kids happy and healthy. For my specialty, it’s to maintain the health of the kidneys. Infections can damage the kidneys. Once you have scarring of the kidneys, you don’t get your kidney tissue back. The liver, on the other hand, can regenerate after an injury. The kidneys don’t regenerate. Once you scar and damage the kidney, you’ve then lost that kidney tissue. The ultimate worst-case scenario would be losing your kidneys because of recurrent infections, losing your kidney function or losing one kidney or both. Our goal is to prevent any renal damage and keep children with urine infections out of the hospital.

Q: So, parents should take this very seriously. And if they see these symptoms in their children, they should call a physician.

Dr. Berkman: Yes. I would say the lower urinary tract symptoms, certainly, if the kids are talking, can be addressed and treated early.

With early and appropriate treatment, children have no long-term sequelae, which means no long-term complications or consequences of having lower urinary tract infections involving the bladder, and no long-term complications or consequences of upper urinary tract infections involving the kidney.

An infant with a fever needs to be treated within 48 hours. A lot of times, a virus may be going around town, and you may take your child to urgent care, and they’ll say, “Well, gosh, could you potentially just have a virus? Why don’t you watch and just see how that’s going to resolve?” With a fever of unknown origin, I like to have a urine analysis just to document that it’s not urine in origin.

If a child has recurrent febrile urinary tract infections, which means that the bacteria has made it into the kidney, then you can have long-term issues, like renal scarring and renal damage.

The worst-case scenario is if a child has a stone obstructing the urinary tract, which gets infected. In those situations, a child would come in with pain in their side, fever, nausea and vomiting, then you do some imaging studies. A urinary tract infection with obstruction plus infection requires emergency care. A child with a stone plus infection really needs to be drained right away. They need to be in the hospital because they can have the most adverse consequences if not treated.

Q: Do you have any other advice for parents about recognizing, preventing or treating UTIs?

Dr. Berkman: I would say that prevention is the most important thing. Maintain good hygiene. For the females, wiping front to back. For boys, if they have foreskin, they need to clean the foreskin. And if there’s problems that they can’t retract the foreskin over time, then that can lead to recurrent infections and problems.

Also, maintaining proper elimination, if kids have underactive bladder or they hold their urine too long. They may want to keep playing with their friends and not get up to urinate, so they hold their urine for an extended period of time. The urinary tract needs to be emptied regularly, at least every 3-4 hours, or the bacteria have a good time and grow and flourish. So, emptying regularly, at least every 3-4 hours, is important.

At the other end of the spectrum is an overactive bladder. Some kids have overactive bladders and need some medication to relax the bladder to allow them to hold 3-4 hours.

If parents see either of those extremes, they need to be addressed.

And then constipation, for some reason, is very common in some of these dysfunctional elimination kids. Maintaining soft daily bowel movements, I think, is very helpful in preventing infections.

Finally, watching for the signs and symptoms of urinary tract infection such as burning, urgency, blood, and certainly a fever of unknown origin. If they see those signs, I would want them to seek evaluation and get the urine checked.