Recurrent Urinary Tract Infections and Related Conditions

What Are UTIs?

Urinary tract infections (UTIs) happen when bacteria (germs) get into the kidneys, ureters, bladder, or urethra. UTIs are common in kids, especially girls and uncircumcised boys.

What Are Recurrent UTIs?

Some kids get UTIs again and again — these are called recurrent UTIs. If not treated, recurrent UTIs can cause kidney damage, especially in kids younger than 6. So it's important to know how to recognize the signs of these infections and get help for your child.

What Are the Signs & Symptoms of UTIs?

Symptoms of a UTI can include:

• pain when peeing
• changes in frequency of urination
• changes in appearance or smell of pee
• fever
• chills
• loss of appetite
• nausea
• vomiting
• lower abdominal pain
• lower back pain or discomfort

UTIs also can cause kids to wet their pants or the bed, even if they haven't had these problems before. Infants and very young children may only show nonspecific signs, such as fever, vomiting, or decreased appetite or activity.

Types of UTIs

Common types of UTIs include:

• cystitis: this bladder infection is the most common type of UTI. Cystitis occurs when bacteria move up the urethra (the tube-like structure that allows urine to exit the body from the bladder) and into the bladder
• urethritis: when bacteria infect the urethra
• pyelonephritis: a kidney infection caused by infected urine flowing backward from the bladder into the kidneys or an infection in the bloodstream reaching the kidneys

What Conditions Are Related to Recurrent UTIs?

Recurrent UTIs sometimes happen along with other conditions, such as:

• vesicoureteral reflux (VUR), which is found in 30%–50% of kids diagnosed with a UTI. In this congenital (present at birth) condition, pee flows backward from the bladder to the ureters. Ureters are thin, tube-like structures that carry pee from the kidney to the bladder. Sometimes the pee backs up to the kidneys. If it's infected with bacteria, it can lead to pyelonephritis.
• hydronephrosis, which is an enlargement of one or both kidneys due to backup or blockage of urine flow. It's usually caused by severe VUR or a blocked ureter. Some kids with hydronephrosis might need to take daily low doses of antibiotics to prevent UTIs until the condition producing hydronephrosis gets better or is fixed through surgery.

But not all cases of recurrent UTIs can be traced back to these body structure-related problems. For example, dysfunctional voiding — when a child doesn't relax the muscles properly while peeing — is a common cause of UTIs. Not peeing often enough (infrequent urination) also can also increase a child's risk for recurrent infections. Both dysfunctional voiding and infrequent urination can be associated with constipation.

Rarely, unrelated conditions that harm the body's natural defenses, such as diseases of the immune system, also can lead to recurrent UTIs. Use of a nonsterile urinary catheter can introduce bacteria into the urinary tract and also cause an infection.

How Are Urinary Abnormalities Diagnosed?

Although UTIs can be treated with antibiotics, it's important for a doctor to rule out any underlying abnormalities in the urinary system when UTIs happen repeatedly. Kids with recurrent infections should see a pediatric urologist to see what is causing the infections.

Some problems can be found even before birth. Hydronephrosis that develops before birth can be detected in a fetus by ultrasound as early as 16 weeks. In rare cases, doctors may consider neonatal surgery (performing surgery on an unborn baby) if hydronephrosis affects both kidneys and poses a risk to the fetus. Most of the time, though, doctors wait until after birth to treat the condition, because almost half of all cases diagnosed prenatally disappear by the time a baby is born.

Once a baby suspected to have hydronephrosis or another urinary system abnormality is born, the baby's blood pressure will be monitored carefully, because some kidney problems can cause high blood pressure. An ultrasound may be used again to get a closer look at the bladder and kidneys. If the condition appears to be affecting both kidneys, doctors usually will order blood tests to measure kidney function.

Testing

If an abnormality of the urinary tract is suspected, doctors might order tests to make an accurate diagnosis, including:

Ultrasound
Using high-frequency sound waves to "echo," or bounce, off the body and create a picture of it, an ultrasound can detect some abnormalities in the kidneys, ureters, and bladder. It can also measure the size and shape of the kidneys.

When an ultrasound points to VUR or hydronephrosis, a renal scan or voiding cystourethrogram (VCUG) might give doctors a better idea of what's going on.

Renal scan (nuclear scan)
Radioactive material is injected into a vein and followed through the urinary tract. The material can show the shape of the kidneys, how well they function, if there is damaged kidney tissue, and the course of the urine. A small amount of radiation is received during the test and leaves the body in the urine.

Voiding cystourethrogram (VCUG or cystogram)
A catheter (a hollow, soft tube) is used to inject an opaque dye into the bladder. This X-ray test can diagnose VUR and identify problems with the bladder or urethra.

Cystoscopy
A cystoscope uses lenses and a light source within a tube inserted through the urethra to directly view the inside of the bladder. It's used when other tests or symptoms indicate a possible bladder abnormality.

Intravenous pyelogram
Opaque dye is injected into a vein, and then X-rays are taken to follow the course of the dye through the urinary system. Although this test is still used sometimes, the renal MRI and renal scan have replaced intravenous pyelogram in most cases.

Magnetic resonance urography (MR-U)
This procedure, which makes a magnetic resonance imaging (MRI) scan of the urinary tract without the use of dyes or radioactive materials, has been shown to be as accurate as other scans and is now typically done in place of an intravenous pyelogram.

How Are Recurrent UTIs Treated?

Treatment for recurrent UTIs depends on what's causing them in the first place. Sometimes the answer is as simple as teaching a child to empty the bladder as soon as he or she has the urge to go.

If a condition like VUR is causing the infections, the solution is a bit more complicated. Kids with VUR must be watched closely, because the condition can lead to kidney infection (pyelonephritis) and kidney damage. Usually, surgery isn't necessary because many kids outgrow the condition.

Some kids with VUR benefit from daily treatment with a small amount of antibiotics, which can also make surgery unnecessary. Kids with VUR should see a pediatric urologist, who can decide if antibiotic treatment is the best option.

In some cases, surgery is needed to correct VUR. The most common procedure is ureteral reimplantation, in which one or both of the ureters are repositioned to correct the backflow of urine from the bladder. This can be done through a small incision. The success rate for this surgery is high, although not everyone is a good candidate for it.

Kids may be candidates for ureteral reimplantation if they:

• have an intolerance to antibiotics
• get recurrent infections while on antibiotic treatment
• have severe, or "high-grade," reflux
• are older kids and teens with reflux

An alternative to ureteral reimplantation is endoscopic injection of a material to block the entry of the ureter into the bladder and prevent VUR. In this procedure, a narrow tube called an endoscope is inserted through the urethra into the bladder. The endoscope has a tiny camera at the tip, so the surgeon can guide it to the proper location and inject the material, which helps keep pee from refluxing back into the kidneys. Endoscopic injection is less invasive than surgery, but the results are not as good. A pediatric urologist can help families decide the best treatment for a child with VUR.

Kids who have recurrent infections that are not caused by anatomical defects or other treatable problems may be prescribed antibiotics for months or even years to prevent recurrent infections. This treatment is known as continuous antibiotic prophylaxis.

The Future for Managing Recurrent UTIs

Recent studies have found that women and kids who get recurrent UTIs may lack certain immunoglobins (a group of proteins that fight infections). Some researchers are optimistic that a vaccine may be developed to help boost production of antibodies that fight UTIs. A promising vaccine that would protect against E. coli (the most common bacterium that causes UTIs) is being tested.

How Can I Help My Child?

At home, these things can help prevent recurrent UTIs in kids:

Drinking Fluids
Encourage kids to drink 8 to 10 glasses of water and other fluids each day. Cranberry juice and cranberry extract are often suggested because they may prevent E. coli from attaching to the walls of the bladder. Always ask your doctor, though, if your child should drink cranberry juice or cranberry extract, because they can interfere with some medicines.

Good Bathroom Habits
Peeing often and preventing constipation can help to prevent recurrent infections.

Multivitamins
Vitamin C acidifies pee, making the environment less friendly to bacteria. Vitamins designed for kids are generally safe, but always ask your doctor before increasing the dose beyond the currently recommended daily allowance.

No Bubble Baths
Kids should avoid bubble baths and perfumed soaps because they can irritate the urethra.

Frequent Diaper Changes
Kids in diapers should be changed often. This prevents stool from having prolonged contact with the genital area, which can lead to bacteria moving up the urethra and into the bladder.

Proper Wiping
Girls should wipe from front to back after using the toilet to reduce exposure of the urethra to UTI-causing bacteria in stool.

Cotton Underwear
Breathable cotton underwear is less likely to encourage bacterial growth near the urethra than nylon or other fabrics.

Regular Bathroom Visits
Some kids may object to using the school bathroom or may become so engrossed in a project that they delay peeing. Kids with UTIs should pee at least every 3 to 4 hours to help flush bacteria from the urinary tract.

When Should I Call the Doctor?

As soon as you suspect that your child has a UTI, call your doctor. The doctor may recommend another urine culture after treatment to be sure that the infection has cleared.

If your child has from recurrent UTIs, consult a pediatric urologist, who can do a thorough evaluation and order tests for urinary system abnormalities. In the meantime, follow your doctor's instructions for treating a UTI.