Presented by Valari Cathey APRN MS CPNP Department of Pediatric Urology OU Childrens Physicians Pediatric Urology Team Dominic Frimberger MD Dorsa Ahlefeld APRN New peds urologist coming in July 2018 ID: 920549
Download Presentation The PPT/PDF document "Bladder and Bowel Dysfunction & UTIs..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Bladder and Bowel Dysfunction & UTIs in Children
Presented by Valari Cathey, APRN, MS, CPNP
Department of Pediatric Urology
OU Children’s Physicians
Slide2Pediatric Urology Team
Dominic
Frimberger, MD, Dorsa Ahlefeld, APRN
New
peds urologist coming in July 2018:Adam Rensing, MDBalagee Sundaram, MD
Slide3Objectives
Describe common terms associated with bladder and bowel dysfunction along with age associated norms from the
ICCS (International Children’s Continence Society)
Explore potential etiologies of abnormal toileting
habitsDiscuss management and treatment options including medications to address common types of bladder bowel dysfunction
Slide4Slide5Terminology
Terminology is changing and the term dysfunctional elimination syndrome (DES) is now discourage by the ICCS (International Children’s Continence Society)
Journal of Urology, 191 (6): 1863-1865, June, 2014
http://www.jurology.com/article/S0022-5347(14)00245-6/fulltext
Slide6Terminology
Bladder Bowel Dysfunction (BBD) now recommended
More descriptive term
Encompasses the parallel dysfunction
Broader term which can be subcategorized into lower urinary tract (LUT) dysfunction and bowel dysfunctionAustin PF, Bauer SB, Bower W, et al. The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (2014). The Journal of Urology, 191 (6): 1863-1865/doi.org/10.1002/nau.22751. [PubMed]
Slide7Bladder Bowel Dysfunction
Abnormal
potty
habits develop in a variety of age groups and can last for days, weeks, months or
yearsLUT symptoms are characterized after 5 years of age for incontinence disorders and after a minimum of 4 years of age for bowel disordersHowever, the terminology may be applicable to those <5 years of age if the child has achieved voluntary controlAges used by the DSM-5 and ICD-10
Austin PF, Bauer SB, Bower W, et al. The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (2014). The Journal of Urology, 191 (6): 1863-1865
Slide8Visual Learners!!
Common pediatric problem
20-25% referrals to pediatric urologists
Wide spectrum of conditions
Daytime incontinenceEnuresisUnderactive bladderOveractive bladder
Dysfunctional voidingVoiding postponement
Slide9Incontinence- continuous or intermittent
Continuous incontinence
leaks
day and night
Intermittent incontinence leakage of urine in discrete quantities Congenital malformationsectopic ureterexstrophy variant
Functional loss of external urethral sphincter function external sphincterotomyI
atrogenic causes vesicovaginal fistula
Daytime incontinence
occurs while awake
Enuresis
o
ccurs only during sleep
should not be used to refer to daytime incontinence
Austin
PF, Bauer SB, Bower W, et al. The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (2014). The Journal of Urology, 191 (6):
1863-1865 ht
tps
://doi.org/10.1002/nau.22751. [PubMed]
Slide10Enuresis
Monosymptomati
c
Non-
monosymptomaticEnuresis without other lower urinary tract symptomsPrimarySecondaryChildren with other lower urinary tract symptomsPrimary
SecondaryAustin PF, Bauer SB, Bower W, et al. The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (2014). The Journal of Urology, 191 (6): 1863-1865
https://doi.org/10.1002/nau.22751
. [
PubMed
]
Slide11Normal Urinary Voiding
11
Slide12Voiding Dysfunction
Neurogenic
- result from disruption of innervation of the bladder or external sphincter (congenital anomalies like myelomeningocele)
Anatomical
- structural abnormality (anatomical defect where the ureter inserts distal to the bladder neck) Functional- maturational delay or abnormally acquired toileting habitsDysfunctional voiding: Child habitually contracts the urethral sphincter or pelvic floor during voiding and demonstrates a staccato pattern
on uroflow or “spinning top urethra” on VCUG.
Note: This is a term associated with a neurologically intact patient
Austin PF, Bauer SB, Bower W, et al. The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (2014). The Journal of Urology, 191 (6): 1863-1865
Slide13Factors Contributing to Abnormal Potty Habits
Disposable diapers
Family dynamics
Children’s hectic schedules
Modern day games and activitiesBathroom access and fearsConstipating diet Bladder irritants like sodas, juices
Slide14Abnormal Toileting Habits
Lower
urinary tract symptoms
R39.9
Involuntary urine leakage immediately after completion of voiding (Post-void dribbling- N39.43)Daytime accidents or uncontrolled urine leakage (Urge incontinence-N39.41)Bedwetting (Primary or secondary nocturnal enuresis-N39.44)
Slide15Holding Maneuvers
The technique is named after Dr. S.A. Vincent of Belfast City Hospital who first described it in a Sep 17, 1966 article in
The Lancet
(
"Postural Control of Urinary Incontinence: The Curtsy Sign"). Vincent learned of the technique from the mother of an 8-year-old girl
.
Slide16A thickened bladder wall points to a longstanding history LUTS, UTI and at times bladder pathology from outlet obstruction in boys
Normal values do not exist and bladder wall thickness varies depending on degree of bladder fullness
Austin PF, Bauer SB, Bower W, et al. The
Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (2014). The Journal of
Urology, 191 (6): 1863-1865Bladder wall thickness
Slide17Dysuria
Burning with urination
(
Dysuria-R30.0)
Causes UTIsLocal skin irritationConcentrated urineHolding behaviorsTreatmentTime voidEncourage more water
Girls change to wide legged voiding
posture and slow downEncourage uncircumcised boys
to retract foreskin with urination
Screen for labial adhesions
Slide18Wrong Way but love enthusiasm
Slide19Labial Adhesions
3-30% of girls, most asymptomatic
Etiology uncertain, one theory is low estrogen levels in these prepubertal girls
Theory supported since always resolves with puberty as natural estrogen levels increase
Slide20Labial Adhesions
Only treat if symptomatic
Dysuria
Post-void dribbling
UTIsTreatmentsMedical management (up to 70% recurrence)Estrogen cream (Premarin) applied to labia 2x/day for 4-6 weeksSteroid cream is also an option (Diprolene)Surgical therapy (up to 50% recurrence)Rarely perform at our institution
Slide21Urinary Frequency
Most children 3-12 years of age void 3-7 times
daily
Daytime urinary frequency is children who void
>8 times per day while awake increased frequency of urination-R35.0Causes Exclude UTI and DM concerns
firstConstipationCertain fluids promote diuresisFailure to
empty-rareTreatmentsAvoid known bladder irritantsManage constipation
The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (
2014). The Journal of Urology: 1863-1865.
Slide22Avoiding Known Bladder Irritants
Caffeinated beverages
Teas, coffees, chocolate drinks, and sodas
Carbonated drinks
SodasCitrus drinksOrange juice and lemonadeCarbohydrate containing beveragesKool-Aid, Powerade, Gatorade, Vitaminwater
Slide23Stool Behind Bladder
Until proven otherwise all children with bladder disorders are constipated.
Slide24Constipation
Large retrospective studies have shown that in 234 children with chronic constipation
29% had daytime urinary incontinence
34% had nighttime urinary
incontinence11% UTIsIn a 1997 article, Loening-Baucke reported that the relief of chronic constipation resulted in disappearance of daytime urinary incontinence by 89% and nocturnal enuresis by 63% and disappearance of recurrent UTIs in all with no anatomical problems
Loening-Baucke V. Urinary incontinence and urinary tract infection and their resolution with treatment of chronic constipation of childhood. Pediatrics. 1997;100:228–32. https://doi.org/10.1542/peds.100.2.228. [
PubMed]
Slide25Bristol Stool Scale
Slide26Treatment of Constipation
Step #1
-
Start
from below first with enemas or suppositories if family willing. Glycerin or Ducolax suppositories start working in 15-60 minutes. Enemas work best! They start working in 1-5 minutes. Give a suppository or enema 3 days in a row.Then give one enema or suppository weekly until accidents resolveand regularity established.
Slide27Treatment of Constipation
Step #2
-
Give 1-2 days in a row on the weekend.
Repeat a laxative every weekend until symptoms resolve and bowel movements are more regular (daily, soft, long and skinny poops).Chocolate ex-lax ½ to 2 squaresPedia-Lax tabletsStart working in 30 minutesDuration of action 6 hours 1-3 tablets 2-5 years of age3-6 tablets 5 years and older
Slide28Treatment of Constipation
Step #3-
Start Miralax following the bowel clean and continue daily
Start the child on Miralax (Polyethylene glycol) the day after the bowel clean out is done.
5 years of age and younger ¼ of the adult dose daily. All older children on ½ of adult dose daily. Give the medication with 1/2- to 1 cup of fluid at any meal. Recommend parents adjust the dose as needed, every 3-4 days up to 2 capfuls daily if needed. Take the medication as long as needed. It is an osmotic laxative, only traps water in the stool.
It does not cause dependence or stimulate a bowel movement. It works to soften the stool.
Slide29Treatment of Constipation
Step #4-
Start immediately
Make sure child is drinking lots of water or water based fluids to help keep the stool soft.
The urine is the best indicator of hydration. The lighter in color it is the better. Then slowly increase dietary fiber (fruits, vegetables, whole grains) about 25 grams per day. Decrease constipating foods (meats, dairy and white processed foods).
Slide30Miralax clean out
Child’s
dose is typically 1 capful for every year of age mixed in 4-8 ounces of fluid over 4-6 hours.
Example
: 8 year old=8 capfuls, take 1 capful every 30 minutes for 4 hours to total 8 capfuls of Miralax/PEG.
Slide31Proper Posture
Slide32Penile Pain
Typically referred pain from constipation or erections
Slide33Meatal Stenosis
Stenotic meatal opening resulting from how it healed after circumcision
A problem usually detected once toilet training begins
Upward deflection of urine stream with each urination
We watch them urinate to verify diagnosisTreat with a clinic meatotomy by one of the surgeons under local anestheticCan go to OR if necessary
Slide34Causes of Urinary Urgency
As
the bladder contracts against a closed sphincter the bladder thickens and becomes more forceful and quick to empty.
A
thickened bladder wall points to a longstanding history LUTSNormal values to not exist and thickness varies depending on degree of bladder fullnessThick if greater than 3 mm when bladder fullThick if greater than 6 mm when bladder full
The Standardization of Terminology of Lower Urinary Tract Function in Children and Adolescents: Update Report from The Standardization Committee of the International Children’s Continence Society. (2016). Neurourology and Urodynamcis 35: 471-481.
Slide35Overactive Bladder
International Children’s Continence Society, overactive bladder (OAB) is “urinary urgency, usually accompanied by frequency and
nocturia
, with or without urinary incontinence, in the absence of urinary tract infection or other obvious
pathologythe most common voiding dysfunction in children According to two fairly recent, large-scale studies, the Prevalence of OAB in children is in the 15–20% range a higher prevalence of OAB in boys
Chung et al noted a decreasing prevalence of OAB with age23.0% at 5
years old 12.2% at 13 years old
Chung JM, Lee SD, Kang DI, et al. Prevalence and associated factors of overactive bladder in Korean children 5–13 years old: A nationwide multicenter study. Urology. 2009;73:63–7. https://doi.org/10.1016/j.urology.2008.06.063. [PubMed]
Slide36Daytime Urinary Incontinence
>1 episode per month with 3 episodes over three months
Typically decreases with age
5-6 year olds -10%
6-12 year olds -5%12-18 year olds -4%
Slide37Risk factors for urge incontinence
Female gender
History of nocturnal enuresis
Urinary tract infections
Encopresis
Slide38Initial Evaluation
History
Physical examination
Studies
UrinalysisUroflowPVR+/- KUB
Slide39Uroflow
Slide40Flow curves
Uroflow
curve patterns. A. Bell-shaped. B. Tower-shaped. C. Staccato-shaped. D. Interrupted-shaped. E. Plateau shaped
Slide41Staccato flow pattern
Slide42History
Age of toilet training and/or any dry days or nights
Number of voids during the day
Frequency of incontinent episodes
Type of incontinenceBefore or after urinating- after vaginal refluxDribbles or saturatesDay only or day and nightSymptoms like urgency or dysuria
Voided volumesMaximum voided volume can be compared with
expected bladder capacity, as deduced from the standard formula [30 + (30 x age)]ml
I. Franco, A. von
Gontard
, M. De
Gennaro
, et
al.Evaluation
and treatment of
nonmonosymptomatic
nocturnal enuresis: a standardization document from the International Children's Continence Society
Slide43History
Bowel habits
Get specific, ask kid and parents
How often? Large? Pebbles? Painful? Hard? or Soft?
Use Bristol stool scale Dietary intakeNibbler/grazer or meal eaterFluid choicesHistory of urinary tract infectionsFever or afebrileBag, cup or catheterized collectionsDevelopmental delays Children who are developmentally delayed may also be delayed in gaining bladder control
Slide44History
Comorbidity
Family
history Must ask specifically about nocturnal enuresis
Who and for how long? Social historyCaregiversDaycare and/or school settingDoes teacher allow to use restroomSend a school note to allow for voiding at least every 2 hours
Slide45Comorbidity
In
a large study
of 8213 children aged 7½ to 9 years, children with daytime
wetting had significantly increased rates of psychological problems:ADHD 25%Separation anxiety 11%Oppositional behavior 11%Conduct problems 12% 10,000 children aged 4-9
years were analyzedDelayed development, difficult temperament and maternal depression/anxiety were associated with daytime wetting and soiling
Joinson C, Heron J, Butler U, von Gontard A. Psychological differences between children with and without soiling
problems. Pediatrics 2006;117:1575e84.
Joinson
C, Heron J, von
Gontard
A, Butler U, Golding
J,
Emond
A. Early childhood risk factors associated with
daytime wetting
and soiling in school-age children. J
Pediatr
Psychol
2008;33:739e50
.
Slide46Physical Examination
Focus on neurological and urological abnormalities
Lower back
Signs of tethered cord- sacral dimpling, tuft of hair or assymetrical gluteal folds
Neurological examinationAbnormal gaitExternal urological examinationLabial adhesions can lead to post-void dribbling and dysuriaObservation of urination Helps evaluate voiding posture and if they strain (valsalva)
Slide47Medical Tests Available
Urinalysis
Uroflow
Post-void bladder
ultrasound+/- KUBRenal ultrasound hematuria Recurrent UTIsVoiding cystourethrogram (VCUG)Febrile UTIs
MRI of the spine order if urodynamics abnormal
Video urodynamicsnever achieved a dry day after complying with program
Cystoscopy
greater
than 15 years of age with hematuria
Urethral dilation is not recommended
Slide48PVR
Children 4 - 6 years old:
Single PVR >30 ml or >21% of bladder capacity (BC)
Repetitive PVR >20 ml or >10% BC
Children 7 - 12 years old: Single PVR >20 ml or 15% BCRepetitive PVR >10 ml or 6% BCStandard conditions:Not be under-distended (<50%)Not over-distended (>115%) in relation to the EBC; PVR obtained immediately after voiding (<5minutes).
Slide49Urodynamic testing
Routine urodynamic testing in the evaluation of urinary incontinence is not recommended for the following reasons.
Invasive
Expensive
Requires specialized equipment and trainingTypically not necessary to make the diagnosis or affect outcome
Slide50Always start with Urotherapy
Conservative management is generally the initial approach to treating voiding dysfunction
Standard
Urotherapy
:Timed voiding schedulesAltering voiding postureTake more time goOptimizing hydrationAvoiding known bladder irritants Treatment of constipationVoinding diary 48
hours (not necessarily recorded on 2 consecutive days)
Slide51Timed Voiding
Voiding before the child feels the urge to urinate
At least every 2 hours at home and school
Send a school note
Some teachers will set their telephone to alarmYoung children and those with ADHD will need to be remindedWatch alarm reminders available for older children (>6 years)Taking the time to empty to completionDouble voiding if needed 2-3 times/day at homeAvoiding Valsava voidingUse a pinwheel for teaching
proper muscle contraction and relaxationProper positioning
Slide52Vibrating watch reminders
Not covered by insurance
Range in price from $40-$80
Available at pottymd.com and bedwettingstore.com
Slide53Hydration
Water, Water, Water
Calculating water needs
Iphone App: Water Your Body for $0.99
40 pounds (4 years)1.5 - 16 ounce bottles60 pounds 2 - 16 ounce bottles80 pounds2.5 – 16 ounce bottlesEstimate- Easiest way about ½ their body weight in ounces of water per day
Alternatives:
Crystal light
Propel
Sugar-free Kool-Aid
Mio
Slide54Biofeedback Training
Used for non-neurogenic dysfunctional voiding, those with detrusor-sphincter dyssynergia
Teaches children how to voluntarily control their sphincter and pelvic floor muscles
Appears to reduce voiding dysfunction in observational studies especially those with postvoid residual volumes
1] Kaye, J.D. and Palmer, L.S., 2008. Animated biofeedback yields more rapid results than nonanimated biofeedback in the treatment of dysfunctional voiding in girls. The Journal of urology, 180(1),
pp.300-305. [2] Wenske
S, Combs AJ, Van Batavia JP, Glassberg KI, 2012. Can staccato and interrupted/fractionated
uroflow
patterns alone correctly identify the underlying lower urinary tract condition? The Journal
of urology, 187 (6), pp. 2188–2193.
USA
Slide55Pharmacologic Therapy
The most commonly used anticholinergic agent is oxybutynin (Ditropan).
Works by decreasing the frequency of uninhibited bladder muscle contractions during filling phase and increases bladder capacity.
Comes in liquid and tablet formulation
1 mg/ml and 5, 10 and 15 mg tablets immediate and extended releaseER shown to be superior to IR in studiesER needs to be swallowedIR chew or swallow Recommended daily dose is 0.3-0.6 mg/kg Max 20 mg/dayStart twice daily and increase to three times daily if needed
Ramsay S, Bolduc Stephane. Overactive bladder in children. Can Urol
Assoc J. 2017 Jan-Feb; 11(1-2Suppl1): S74-S79.
Slide56Oxybutynin
The
immediate-release (IR) (Ditropan
®
) and extended-release (ER) (Ditropan XL®) formulations of oxybutynin are currently the only pharmacological agents FDA approved for the treatment of OAB in children age 5 years and older in North America for IR and 6 years and older for ER.However, only one small clinical trial published has evaluated the efficacy compared to placebo in children. It showed no improvement in frequency of daytime wetting between oxybutynin and placebo. Observational studies report improvement in symptoms. Adult data has shown a reduction in urinary incontinence.
Chang SJ, Van Laecke
E, Bauer SB, et al. Treatment of daytime urinary incontinence: A standardization document from the International Children’s Continence Society. Neurourol Urodyn. 2017;36:43–50. https://doi.org/10.1002/nau.22911. [PubMed]
Slide57Oxybutynin
Side effects
58% reported no side effects
19% constipation
17% dry mouth14% flushing5% heat intoleranceCNS side effects more common in children typically in first monthHallucinationAgitationSedationConfusionAmnesia
Nightmares
Slide58Primary Nocturnal Enuresis (monosymptomatic
enuresis)
Percentage of children who wet the bed
Chronological age
16%5%1-2%
5 years10 years15 years+
Nocturnal enuresis in children: Management. (2016). www.uptodate.com
Slide59Nocturnal enuresis
Primary
Never achieved nighttime dryness
80% of childrenSecondary
Dry 6 months before the wetting begins20% of childrenAddress underlying stressor if one can be identified but most have no cause and are treated in the same manner as primary enuresisNocturnal enuresis in children: Management. (2016). www.uptodate.com
Slide60Theories about Nocturnal Enuresis
Deep sleepers or sleep disorders
Significant stress or those with psychological issues
Increased urine production at night and ADH
Daytime bowel and bladder problems (20%)Drinking fluids before bedtimeCertain medicationsDiuretics –lithium Familial tendenciesP. Smith. Overcoming Bladder & Bowel Problems in Children. 2004. “What are abnormal potty habits”, p. 49-53. &. H. Bennett, MD. 2005. Waking Up Dry. “Why Kids Wet the Bed.” p. 17-29.
Slide61History
Determine if any period of dryness
Number of wet nights per week
Presence of daytime wetting or symptomsFamily history of nocturnal enuresis
Ask what the family has triedI
Slide62Treatment of Nocturnal Enuresis
Reassuring parents that time is the ultimate cure and that enuresis is not associated with a physical abnormality
Alarm clocks
Dysfunctional elimination program if daytime incontinence present or constipation is an issue
At least 4 years of age or olderBedwetting alarms 6 years and olderPharmacological agents7 years and olderI. Franco, A. von Gontard, M. De
Gennaro, et al.Evaluation and treatment of nonmonosymptomatic nocturnal enuresis: a standardization document from the International Children's Continence Society. Journal of Pediatric Urology (2013) 9, 234e243y.
Slide63Bedwetting Alarms
Emits an auditory and/or tactile stimulus in response to wetting
A behavioral conditioning approach
The most effective treatment option for enuresis
50-80% successfulTypes of alarmsWearable alarmsWireless alarmsBell-and-pad alarmsH. Bennett, MD. 2005. Waking Up Dry. “The Bedwetting Alarm.” p. 99-112.
Slide64Slide65What to expect from alarms
Most alarm users do not respond without assistance to the alarm in the beginning
Caregiver’s must go in and wake the child then tell them what to do next
As the child starts to make the association, the caregivers’ role is less
The first few weeks are the most difficultCan take 6-12 weeks to achieve continence
Slide66Bedwetting Alarms
Families have to be motivated
May not be an option if child shares a room with sibling
Need to be used nightly
No insurance plans cover the cost of an alarmObtain over the internet or via telephonewww.bedwettingstore.comwww.pottymd.com
www.amazon.comCost average $90 ($60-$200)
H. Bennett, MD. 2005. Waking Up Dry. “The Bedwetting Alarm.” p. 99-112.
Slide67Medications
DDAVP
Since December 2007, the nasal spray is no longer FDA approved for treatment of enuresis due to the risk for hyponatremic seizures
Enhances reabsorption of water in the kidneys by increasing cellular permeability of the collecting ducts
The oral dose titrated from 1-3 tablets (0.2-0.6 mg)every 7-10 daysTake prior to bedtimeFDA approved for children greater than or equal to 6 years of age
Slide68Medications
DDAVP TABLETS
Must take medication nightly to stay dry
25% exhibit a reduction in wetting
25% become completely dry50% no changeVery expensive but covered by most insurancesCost 0.1 mg tablet $4.13 and 0.2 mg tab $5.96 ($180 to $540 per month)Limit fluids 1 hour before and 8 hours after administrationNot recommended if child has illness (vomiting, diarrhea, fever)
Slide69Cochrane Review-
Drugs for nocturnal enuresis in children (other than desmopressin and tricyclics
).
Evidence
suggests combination therapy with anticholinergic therapy increased the efficacy of other established therapies such as imipramine, desmopressin and enuresis alarms by reducing the relapse rates, by about 20%, not possible to identify the characteristics of children who would benefit from combination therapy
Slide70Medications
Imipramine (has dual alpha agonist and anticholinergic activity)
Decreases time spent in REM sleep
Stimulates ADH secretion
Relaxes detrusor muscleDosing25 mg for children 5 to 8 years 50 mg for older children up to 12 years of age75 mg in children > 12 years of ageEffect is quick and stop if no changes after a 3 week trial with a week at max doseManagement of nocturnal enuresis in children. (2009). www.uptodate.com
Slide71Medications
Imipramine
Side effects are uncommon
5% develop neurological symptoms
NervousnessPersonality changeSleep disturbanceCardiovascular disturbance- obtain baseline and periodic EKGs in those with cardiac diseaseEspecially in overdoseBlack box warningIncreased possibility of suicide in those with depressive symptoms
Slide72Causes of Urinary Tract Infections
Abnormal toileting habits are the most common cause of urinary tract infections in children
Not emptying the bladder often enough
Constipation
Poor hygieneOther contributing factorsGenderPoor bladder immunityStructural anomalies associated with febrile urinary tract infections
Slide73Common Pathogens
The Culprits
E. Coli Found in 90% of UTIs
Escherichia Coli
EnterococcusP. aeruginosaKlebsiella sp.
Proteus sp.Enterobacter sp.Coag-negative staphStaph aureus
Candida sp.
Slide74Specimen Collection
Specimen Collection
Catheterization Best Practical Method
Clean Voided Specimen
80% AccuracyCatheterized Specimen95% AccuracySuprapubic Aspiration
21 or 22-guage needle 1-2 cm above PS99 % accuracyRarely used in clinic practice
Bagged Specimen80% contaminated, false +NEVER RECOMMENDED
Slide75Which of these is a UTI if a CCUA?
50,000-60,000 cfu/ml of mixed flora
>100,000 cfu/ml of Proteus mirabilis
15,000 cfu/ml of beta Streptococcus, group B
>100,000 cfu/ml of E. coli
Slide76Urine Cultures Gold Standard-
Dipstick UAs are screening tools
Clean catch urine specimens
Culture shows greater than 100,000 cfu/ml of a single organism
Catheterized urine collectionsGreater than 50,000 cfu/ml
Slide77Probiotics for Preventing UTIs
No significant benefit was demonstrated when compared to placebo or no treatment in children or adults
Small studies
Poor methodological reporting
Schwendger ER, Tejani AM, Lowewen PS. Probiotics fro preventing urinary tract infections in adults and children. Cochrane Database Syst Rev. 2015 Dec 23; (12).
Slide78Testing available- VCUG images
Right grade 3 VUR, Bifid system
Renal ultrasound- if hematuria or UTIs
Voiding cystourethrogram (VCUG)- if UTIs <5 years of age or febrile culture documented UTIs (>102 degrees) at any age
Slide79DMSA Nuclear Renal Scan to assess for renal scarring
Slide80Questions?