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Seminar to discuss urinary tract
infections in the very young
rinary tract infection
(UTI) is a common
cause of fever in infancy
and is probably the most
common serious childhood
bacterial infection. A seminar
Monday, Oct. 22, at this year’s National
Conference and Exhibition will focus
on how pediatricians should manage a
young patient with UTI.
“After the First UTI: Controversies
and Consensus” (S3091) will feature
Ellen R. Wald, MD, FAAP, Chair of the
Department of Pediatrics at the University
of Wisconsin School of Medicine
and Public Health, and Steven G.
Docimo, MD, Vice Chair and professor
of Urology at the University of Pittsburgh
School of Medicine.
Dr Wald will discuss the new AAP
guidelines for managing the initial UTI
in febrile infants and children up to 24
months of age. The original guidelines
were published in 1999. In November
2011, the AAP revised these guidelines
and Dr Wald served on the Subcommittee
on Urinary Tract Infection that was
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responsible for the update.
She will review the guideline’s
seven action statements,
explain the rationale for these
statements, and emphasize
specific revisions.
The most controversial
change is Action Statement 6,
which describes the criteria for performing
a voiding cystourethrogram (VCUG).
The original guideline called for routinely
performing a VCUG after the first febrile
UTI, Dr Wald said, but the updated
guideline calls for postponing a VCUG
until a second UTI occurs or if an ultrasound
shows a worrisome abnormality.
Dr Wald will begin the seminar with
an overview of UTI, reviewing the
pathogenesis, bacterial etiology, signs,
and symptoms. She will define UTI in
terms of the bacterial density required to
determine whether the urine is infected
and review laboratory diagnosis, including
urine dipsticks and microscopy.
“I think that people tend to underestimate
the importance of pyuria,” she
said. “Understanding that both a lot
of bacteria as well an inflammatory
response, which is what the pyuria
indicates, are expected is an extremely
important take-home message. It will
allow the practitioner to know when a
culture result is important as opposed
to when it may be less important.”
Dr Docimo will discuss management
of recurring UTIs, which often require
management of vesicoureteral reflux
(VUR), along with the best ways to
manage voiding dysfunction. He said
voiding dysfunction is one of the most
Ellen R. Wald, MD, FAAP
common risk factors for recurring
UTI, so a physician must
assess for voiding dysfunction
and, if present, manage it aggressively.
All children with recurring
UTIs should be evaluated for
functional voiding disorders
in addition to evaluation for anatomical
issues, Dr Docimo said.
“What we’ve learned over the years,
much to our benefit and the benefit of
the kids that we treat, is that managing
voiding dysfunction and bowel dysfunction
significantly decreases the risk of
infection and, therefore, obviates a lot
of other treatments that we otherwise
might have to employ, including surgery,”
he said.
Non-surgical, non-invasive treatments
include bowel management with longterm
laxatives, timed voiding, double
voiding to empty the bladder, and
biofeedback to encourage pelvic floor
relaxation.
When surgery is indicated, Dr
Docimo said, there are new techniques
that can be done on an outpatient basis
or require an overnight stay. These
advanced techniques maintain the traditionally
high levels of effectiveness in
resolving VUR and decreasing the risk
of pyelonephritis.
“We find that we use surgery less
frequently than in the past, but when
needed, it’s still a relatively common
set of surgical procedures for pediatric
urologists,” he said. “When needed, it’s
very effective — a low-morbidity, highimpact
kind of surgery.”