Urinary Tract Infections & Vesicoureteral Reflux – PediaCast 235
This week PediaCast covers two more common childhood conditions: urinary tract infections and vesicoureteral reflux. Join Dr Mike Patrick, Dr Andrew Schwaderer and Dr Rama Jayanthi in the PediaCast Studio as they discuss causes, diagnosis, medical management, surgical interventions, and prevention. All of this, plus pediatrician-approved, holiday gift-giving ideas!
- Pediatric Urinary Tract Infections (UTI)
- Vesicoureteral Reflux
- Pediatrician-Approved Holiday Gift Giving Ideas!
- Dr Andrew Schwaderer
Nationwide Children’s Hospital
- Dr Rama Jayanthi
Chief of Pediatric Urology
Nationwide Children’s Hospital
- Nationwide Children’s Hospital – Giving Page
- Pediatric Urinary Tract Infections (NCH Health Library)
- Pediatric Urinary Tract Infections (Medscape)
- Vesicoureteral Reflux (NCH Health Library)
- Vesicoureteral Reflux (Medscape)
Announcer 1: This is PediaCast.
Announcer 2: Welcome to PediaCast, a pediatric podcast for parents. And now, direct from the campus of Nationwide Children’s, here is your host, Dr. Mike!
Dr. Mike Patrick: Hello, everyone and welcome once again to PediaCast, a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide Children’s Hospital in Columbus, Ohio. I’d like to welcome everyone to the program. It is episode 235, 2-3-5, for December 12th 2012 and we’re calling this one Urinary Tract Infections and Vesico-Ureteral Reflux.
I know it’s a big word but we’re going to break it down like we always do and explain exactly what it is we’re talking about. We’d like to welcome everyone to the show. It is another common topic for you today – pediatric urinary tract infection, also known as UTIs and I’m sure lots of moms and dads out there know exactly what I’m talking about. And if you don’t, many of you will in the future because a lot of kids do experience this.
And a common contributing factor for pediatric UTIs is something as I mentioned called vesicoureteral reflux. What is it? How does that cause UTIs? How do you diagnose it? How do you treat it? Stay tune because we have those answers for you and of course we’ll answer those same questions for pediatric urinary tract infections as well. And we’ll cover UTIs at all ages of childhood including babies, toddlers, school age kids and teenagers. So that’s all coming your way.
And as always we have two fantastic studio guests to help me talk about these things. Dr. Andrew Schwaderer, MD, is a Pediatric Nephrologist here at Nationwide Children’s Hospital and Dr. Rama Jayanthi, MD, is the Chief of Pediatric Urology also here at Nationwide Children’s. So we’ll introduce the two good doctors to you in a moment.
First, I want to remind Christmas is fast approaching and if you’re like many people who are looking a charitable organization to bless with your end of year gift-giving donation and if you haven’t decided where to give I’d simply ask that you consider helping us. Help the kids here at Nationwide Children’s Hospital.
It’s easy to do, just visit nationwidechildrens.org/giving for all the details. I know it’s an easy link to remember, nationwidechildrens.org/giving, but we’ll also include that link in the Show Notes for this episode 235 over at pediacast.org.
Also I want to remind you that PediaCast is on Pinterest. We have an Episode board where you can share and repin your favorite episodes to help spread the word about the program. We also have a News Parents Can Use board, which is news stories that you won’t find on the podcast. We have important news items and product recalls, you don’t want to miss those. And again we’d encourage you to repin and share your favorite stories to get the word out to other moms and dads.
And finally one quick reminder, if there’s a topic that you’d like us to talk about, because really the show is all about you, if there’s some particular issue that you just want to know more information about that may be affecting your child or someone that you know, it’s easy to get a hold of me just go to pediacast.org, you can click on the Contact link. You can also email email@example.com or call the voice line at 347-404-KIDS, 347-404-K-I-D-S. And you can leave a message with your question that way as well.
Also I want to remind you the information presented in every episode of PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. So if you do have a concern about your child’s health, make sure you call your doctor and arrange a face-to-face interview and hands-on physical examination.
All right. So let’s move on to our studio guests today. Dr. Andrew Schwaderer, MD, is a pediatric nephrologist, which is a fancy way of saying a kidney doctor, here at Nationwide Children’s Hospital. He’s also an Associate Professor of Pediatrics at the Ohio State University College of Medicine.
Dr. Schwaderer serves as the Research Director for the section of Nephrology and his current research interests include kidney stones, renal dysplasia and vesicoureteral reflux.
Dr. Schwaderer is also interested in patient care and teaching and it’s with a warm welcome that we introduce him as a first-time guest on PediaCast. So welcome to the show, Dr. Schwaderer.
Dr. Andrew Schwaderer: Thank you. Glad to be here.
Dr. Mike Patrick: Great. Great having you. I’m also joined today by Dr. Rama Jayanthi, MD, Chief of Pediatric Urology here at Nationwide Children’s Hospital. He’s an Associate Professor of Urology at the Ohio State University College of Medicine and Dr. Jayanthi is interested in all aspects of the medical and surgical management of genitourinary problems in children including such diverse conditions as hydronephrosis, urinary incontinence, hypospadias, urinary tract infections and vesicoureteral reflux.
It’s these last two conditions we’re concentrating on today and we’re lucky to have Dr. Jayanthi here to share his expertise with us. So a warm welcome to PediaCast for you as well.
Dr. Rama Jayanthi: Thank you for asking me to come.
Dr. Mike Patrick: Great. Thank you for being here. Let’s start with Dr. Schwaderer. What exactly is a urinary tract infection?
Dr. Andrew Schwaderer: Simply stated, a urinary tract infection is when an organism that’s not supposed to be in the urinary tract takes up residence there. Commonly, we think about this as bacterial infections but they can also be caused by viruses and protozoa and yeast. And within the diagnosis or the term urinary tract infection there can be a couple of variants. One variant would be a cystitis in which the infection is limited to the bladder. If the infection has ascended up the urinary tract, in the kidney, we term that a pyelonephritis.
Dr. Mike Patrick: Now, who gets urinary tract infections?
Dr. Andrew Schwaderer: Urinary tract infections are very common. They’re probably the most common bacterial infection along with otitis media. So basically, anyone can get them. We commonly think of them as having a female predominance and certainly up to 30% of females will have urinary tract infection at some point in their life, often childhood. However, in the first year of life, males are more likely to have urinary tract infection. So it is something that can affect both genders.
Dr. Mike Patrick: A lot of the conditions that we’ve talked about here in past programs there’s a little bit of a difference between one ethnic group and another. Do you see that with urinary tract infections or does it pretty much affect all ethnic groups equally?
Dr. Andrew Schwaderer: It infects all ethnic groups. It seems to infect Caucasians slightly more than African-Americans, but certainly we see a number of African-Americans that have urinary tract infections.
Dr. Mike Patrick: Sure. So what causes this? How does bacteria and organisms that aren’t supposed to be in the urinary tract, how did they get there?
Dr. Andrew Schwaderer: Unlike a flu or a cold which we would get from another person, a urinary tract infection is caused by bacteria that normally live in one part of the body, most commonly the GI tract that find their way up in to the urinary tract when they shouldn’t be there. So it would be a bacteria that goes from the stool and is able to ascend up in to the bladder even farther into the urinary tract.
Dr. Mike Patrick: Are there any conditions which may make someone a little bit more prone to getting a urinary tract infection than others?
Dr. Andrew Schwaderer: There’s actually a variety of conditions. Sometimes patients will have immunodeficiencies and they’re prone to all kinds of infections and urinary tract infections can be included in that. Other times they’ll have defects where the kidney or the lower urinary tract does not form properly and they can be more at risk for urinary tract infections. And then there can be other conditions such as kidney stones that increase our risk of urinary tract infections if we develop those.
Dr. Mike Patrick: Sure. You’d mentioned that girls typically are more affected than boys outside of the infant period. And I would suspect that’s because the urethra is shorter so it’s easier for skin and stool bacteria to get up in to the bladder, is that correct?
Dr. Andrew Schwaderer: Correct. The bacteria have a shorter course to infect the urinary tract.
Dr. Mike Patrick: Sure. And then one of the other things that can make kids more prone to having recurrent urinary tract infections is this other thing that we’re talking about today this vesicoureteral reflux. So Dr. Jayanthi, what exactly is that?
Dr. Rama Jayanthi: Well reflux is a term that means that when the child voids when the bladder squeezes to get the urine out some of the urine goes back up towards the kidney, not all of it is coming out. Ordinarily, there’s supposed to be a valve mechanism such that when the bladder contracts all the urine comes out of the bladder to the outside. If you have reflux some of that urine can go back up towards the kidneys and thus, if there is any bacteria in the bladder, if you have reflux, it’s easy for those bacteria to get up to the kidneys and cause infection.
Dr. Mike Patrick: Sure. And I would suspect that one of the things that helps to prevent a urinary tract infection from happening is just the act of peeing on a regular basis so that if you have bacteria or microorganisms in the bladder and you’re urinating, you’re expelling those out of the lower urinary tract. And so if you have a situation where some of that urine is going back up toward the kidneys you’re not really getting rid of all the urine and so the bacteria can kind of hang out up there for a longer period of time?
Dr. Rama Jayanthi: Absolutely. Absolutely.
Dr. Mike Patrick: So who gets reflux? Is this something that also is common like urinary tract infections, less common and do we see a difference between ethnic groups or boys versus girls that sort of thing?
Dr. Rama Jayanthi: Reflux can occur in anybody. There seems to be a greater incidence of reflux in Caucasians compared to African-Americans but anyone can have it. Less than the age of one it has equal instance between boys and girls. But after the age of one, probably because infections are less common in boys to begin with, you see this more often in girls.
Dr. Mike Patrick: Sure. Is there a genetic component to it? Do you see it running in families or is it just sort of a sporadic occurrence?
Dr. Rama Jayanthi: There absolutely is a genetic component. Studies have shown that if you screen siblings of children who have reflux up to a third of their brothers and sisters can also have reflux. And it has been shown that offspring, about 60% of children of adults who had reflux when they were younger will have reflux also.
Dr. Mike Patrick: We’re talking again about the valve, so parents can picture this, you’ve got the kidneys and then you’ve got the ureters, which are the little tubes that come down from each kidney to the bladder, and then from the bladder we have the urethra which goes to the outside. So the valves that we’re talking about are between the ureter and the bladder and so they’re supposed to only allow urine to go in one direction down and not back up. Do we know what causes the valve to be abnormal?
Dr. Rama Jayanthi: Strictly speaking, there is no true valve structure that’s there. The way the system is supposed to develop is that that tube, that ureter that brings the urine from the kidneys to the bladder is supposed to go through the bladder wall at an angle. So that’s a healthy amount of muscle supporting the ureter, so that when the bladder squeezes that opening squeezes shut preventing urine from going back up towards the kidneys.
If you have reflux that tube goes directly in to the bladder almost at a right angle. So that there is no muscular support so that when the bladder contracts the urine has free access up to the kidneys.
Dr. Mike Patrick: So really the valve, so to speak, is the muscle wall of the bladder itself.
Dr. Rama Jayanthi: Exactly. It’s more of a valve mechanism.
Dr. Mike Patrick: Gotcha.
Dr. Rama Jayanthi: As opposed to a true anatomical valve.
Dr. Mike Patrick: Of course in that you could see where that would be more of a genetic developmental thing in terms of what angle the ureter goes in to the bladder.
Dr. Rama Jayanthi: Exactly.
Dr. Mike Patrick: Other than urinary tract infections are there any other signs or symptoms associated with this that would alert parents to know that this issue’s going on?
Dr. Rama Jayanthi: Not really. Infections are the most common symptom of having a reflux.
Dr. Mike Patrick: Gotcha. What signs and symptoms do we see? Let’s kind of move back to urinary tract infections here for a moment with Dr. Schwaderer. What signs and symptoms do we see with urinary tract infection?
Dr. Andrew Schwaderer: Yeah. The signs and symptoms depend on the age of the child and the location of infections. So if we have a baby they might only have a very high fever or vomiting. If the child is older and the infection is limited to the bladder we might have urinary frequency where they would normally go to the bathroom every four to six hours but they’re going every hour or every 15 minutes.
We might have urgency where one second they don’t have to go and the next second they have to go urgently and are running to the bathroom and have that be the most important thing for them. If the infection has ascended up in the kidney they might have a very high fever even if they are not in pain or they might have back pain.
Dr. Mike Patrick: Sure. Some kids will have abdominal pain and vomiting associated with it as well?
Dr. Andrew Schwaderer: Correct.
Dr. Mike Patrick: So sometimes parents will come in, I know when I’m in the emergency department they’ll come in and they have bellyache and vomiting and so the parents think they have a little stomach bug and we find that they have a urinary tract infection with those symptoms.
A lot of parents will come in and say ‘my kid’s urine smells funny’. Is smell of urine associated with urinary tract infections?
Dr. Andrew Schwaderer: It can be. It’s very non-specific. There are lots of things that can make the urine smell different. If it’s very concentrated and they haven’t drinking very much it can have a strong odor and that can be misinterpreted as a urinary tract infection.
Dr. Mike Patrick: And sometimes you can see blood in the urine as well if it’s cystitis and sometimes we see kids presenting that way.
Dr. Andrew Schwaderer: Yeah. Sometimes they’ll have pain with urination. Sometimes there’ll be blood that’s just present when we look microscopically, other times it’ll be visible.
Dr. Mike Patrick: Yeah. How do we diagnose urinary tract infection?
Dr. Andrew Schwaderer: To diagnose urinary tract infection we need three things. The first is the signs and symptoms of the urinary tract infections that we just mentioned. The second is we need evidence of inflammation in the urinary tract and this is usually done with a urine dip stick where we can look for products white blood cells, which signify inflammation, or by-products of bacteria that would show urinary tract infection and inflammation.
And then lastly, we need a positive culture. And that is often something that needs to be collected properly. With young infants it needs to be collected with a catheter or otherwise there will be bacteria on the skin that will make it look like it’s a positive culture when it’s really not.
Dr. Mike Patrick: Sure. And, sure, Dr. Jayanthi.
Dr. Rama Jayanthi: If I may just interject.
Dr. Mike Patrick: Yeah. Absolutely.
Dr. Rama Jayanthi: I think that what Dr. Schwaderer just said was extremely important. The fact that you have to have all three of these factors to truly diagnose an infection. Because we often will see kids who have, it may hurt when they urinate or they may have a little bit of blood in the urine but they don’t have any culture that grows bacteria.
Dr. Mike Patrick: Sure.
Dr. Rama Jayanthi: So you have to have all those three things Dr. Schwaderer mentioned to truly diagnose the infection.
Dr. Mike Patrick: You want it to be collected properly in a clean fashion and so with little babies the best way is with a catheter. Younger kids may be able to wipe themselves clean. The worst way would be peeing in a bag or a hat or something where there could be a contamination of bacteria and then the urinalysis and then the urine culture.
And we do see a lot of folks and I think this kind of extends into the adult world a little bit where adults may be diagnosed based on the urinalysis and they may just treat them with an antibiotic and not get the culture and so I just want to stress out there any clinicians who are listening just how important it is to get the culture so that we can identify if and which organism is growing and make sure it’s compatible with whatever antibiotic that we’re using. Would you agree with that?
Dr. Andrew Schwaderer: That’s extremely important.
Dr. Mike Patrick: Yeah. So then kind of extending over to the reflux side of things. How do we diagnose vesicoureteral reflux?
Dr. Rama Jayanthi: Well, to diagnose reflux you have to do a study which involves placing a catheter in the bladder, filling the bladder and taking pictures while the child is urinating. So that’s the only way to truly diagnose reflux, to actually see the urine going back up the wrong way. Unfortunately, there is no simple way to diagnose reflux. It’s nearly impossible to diagnose reflux on a kidney ultrasound study. If you want to diagnose reflux you have to do this invasive study.
Dr. Mike Patrick: Sure. And this is something that we call VCUG.
Dr. Rama Jayanthi: Exactly.
Dr. Mike Patrick: That’s the common name for it. So that you actually can visualize with the contrast what the urine is doing when they’re actually peeing.
Dr. Rama Jayanthi: A real time study.
Dr. Mike Patrick: And this is something that you probably want done at a facility that’s used to doing these because they get kids to actually urinate while there are people around and you’re getting X-rays, it’s probably best done at a pediatric facility.
Dr. Rama Jayanthi: Yeah. Absolutely. And there are two main issues here: (1) to do the study right you have to have people who are used to working with kids and the side comment is you have to have pediatric specialist who knows when you really have to do the study in the first place; because just because a child had a urinary tract infection does not mean that the child needs to have these types of invasive studies performed.
Dr. Mike Patrick: Sure. And we’re going to get to that in just a second. Of course frequent urinary tract infections can be a sign of reflux. How about hydronephrosis where we have sort of a collection of urine around the kidney? You can’t see that on ultrasound. Correct?
Dr. Rama Jayanthi: That’s correct.
Dr. Mike Patrick: But that could be caused from other things as well. And then a lot of parents during the prenatal ultrasound they’ll be diagnosed with having some fluid around the kidney or hydronephrosis. Can you speak to that?
Dr. Rama Jayanthi: Yeah. We do see a lot of children who have dilation in the kidneys. That is fluid that’s backing up within the kidneys that’s picked up even before a child is born and often that can be due to reflux also. And in certain situations after the child is born we will do a VCUG to look for reflux, but it is not needed in all children who had these dilations noted before the child is born.
Dr. Mike Patrick: Sure. Is that something that then you could do serial ultrasounds after they’re born and then if the hydronephrosis is remaining then you think about getting the VCUG, but if it’s going away on its own then you don’t have to?
Dr. Rama Jayanthi: Absolutely. We decide on whether to do the VCUG in those specific situations namely kids with ultrasounds, which are abnormal before birth, based on the degree of dilation that’s present; based on if it’s a boy or a girl; and based on if the child were to have infections at a point in time.
Dr. Mike Patrick: Sure. Dr. Schwaderer, this is something that I think there’s been a little change in terms of how we approach urinary tract infections in babies. In your mind, what is the correct way to sort of work this up? If you have a baby who has a first time urinary tract infection, used to be that they would automatically get a renal ultrasound and a VCUG pretty much automatically, is that still the recommendation or has that changed a little bit?
Dr. Andrew Schwaderer: The recommendations are controversial. The American Academy of Pediatrics just came out with some new recommendations that place some limitations on when they recommended obtaining VCUGs. It used to be done with every urinary tract infection.
There is a study termed the “RIVUR study”, which is designed to answer some of these questions when a VCUG is needed and it is going to be completed in the next year. So that’s hopefully going to give us more conclusive advice that we can give parents.
Dr. Mike Patrick: Sure.
Dr. Andrew Schwaderer: If we have a child that has recurrent urinary tract infections, if we have a child that is having kidney infections with very high fevers that’s at risk for complications, certainly a VCUG is still a very useful test to rule out… a preventable.
Dr. Mike Patrick: So when there’s a controversy like this probably the best thing a parent can do is listen to the advice of their physician. And if they are concerned and the child’s having recurrent urinary tract infections and maybe the doctor is not doing a workup and the parent feels that they should maybe asking for a referral to a pediatric nephrologist to kind of manage and decide what sort of test ought to be done?
Dr. Andrew Schwaderer: Correct. And we actually have a combined pediatric nephrology/urology clinic that’s very well set up for that type of patient that you just mentioned.
Dr. Mike Patrick: Right. Let’s talk a little bit about the treatment of both of these conditions. Dr. Schwaderer, how do you treat a urinary tract infection?
Dr. Andrew Schwaderer: A urinary tract infection if it’s bacterial it is treated with antibiotics. Traditionally, that has been for seven to fourteen days. There are currently research projects looking at shorter courses in the interest of limiting antibiotic exposure, looking at a three to five-day course and seeing if that’s as effective as the longer course.
Dr. Mike Patrick: Sure. When you’re thinking about the longer course versus the shorter course, does the age of the patient come into play a little bit or what you’re talking about as a shorter course OK with that be for infants as well?
Dr. Andrew Schwaderer: The shorter course is fairly well established to be appropriate for many adults. In kids, we still don’t have conclusive evidence. We’re expecting that shortly, but if you have a young child, a baby, we tend to go with the longer course, particularly if they’re more sick and have the high fever and evidence of a kidney infection. If it’s a teenager that just has signs for bladder infection, a shorter course might be more appropriate.
Dr. Mike Patrick: Sure. Now again, I kind of dating myself a little bit, but it used to be when a baby came in with a urinary tract infection they actually got admitted to the hospital, had IV antibiotics, is there a role for IV antibiotics in urinary tract infections anymore?
Dr. Andrew Schwaderer: There is. Certainly, we treat many patients as an outpatient that used to be admitted to the hospital. If the baby is vomiting and not able to tolerate oral IV antibiotics are very helpful if the patient looks extremely sick, which what we would term as “septic”, or looks like the infection has maybe even spread to the bloodstream, IV antibiotics are absolutely necessary.
Dr. Mike Patrick: Sure. And then once a child has been treated with an antibiotic for urinary tract infection, is it necessary for them to have their urine rechecked after the treatment course is over? If they have no symptoms should they still have a follow-up urine check to make sure the infection’s gone?
Dr. Andrew Schwaderer: Many times yes. There are some patients that are older, their symptoms clear up and follow-up culture may not be needed. On the other hand, if they’re young and are not able to describe their symptoms, if it’s a baby, if they have recurrent infections and we aren’t sure if it’s just the same infection that’s being improperly treated, it’s important to do a culture to confirm that you’ve actually cured the infection.
Dr. Mike Patrick: Sure. Let’s talk a little bit about reflux then. What kind of medical management, before we get to the surgical and the things, for kids with reflux, Dr. Jayanthi? What do you for them on the medical side?
Dr. Rama Jayanthi: Well, I think that the main point to remember is that reflux itself does not hurt kidneys, its infection that hurts kidneys. So the whole thrust in the management of reflux is to prevent infections. And so the way we try to prevent infections is the following: (1) the domain stay historically has been keeping the child on a low dose of antibiotic for a period of time trying to prevent the infections as you hope that the reflux will go away. But equally and perhaps even more important is that the families need to be taught specific methods with regard to hygiene, with regard to bladder habits, with regard to bowel management. There are lots of other things that need to be done beyond giving an antibiotic every single day to try to prevent the infections from occurring.
Dr. Mike Patrick: Sure. And so good hygiene so that the bacteria stays on the stool and on the skin and doesn’t get up into the urinary tract. And then also kids, especially little kids, are notorious for they have the feeling like they have to go to the bathroom and they hold it and then we all know that feeling kind of goes away and then it comes back. And so if you have a residual of urine that’s staying in the bladder and they’re not voiding on a regular basis then that’s something else. Sometimes you have to interrupt kids playing and say ‘hey, you need to go, try to go to the bathroom’.
Dr. Rama Jayanthi: Yeah. Absolutely. Kids always have more important things with their lives than peeing and pooping.
Dr. Mike Patrick: Yes. Yes.
Dr. Rama Jayanthi: And they have to take the time to do both.
Dr. Mike Patrick: Right.
Dr. Andrew Schwaderer: Yeah. And another important condition is constipation. When a baby or a child is constipated the colon can become very stretched and they could push on the bladder. Not unlike when a woman is pregnant and the baby, the developing fetus, is compressing the bladder and it can make them feel like they have to go to the bathroom more than what they normally would and they’ll try to hold it in. And often we see kids if we treat the constipation the urinary tract infections will decrease or even resolve.
Dr. Mike Patrick: I have an advance question for you and this one I think will ring true with some of the physicians out there. What if you have a kid who the urine culture comes back and let’s say whatever antibiotic was initially started the bacteria shows itself in the lab to be resistant to that antibiotic, but then you call the parent and they say oh, he’s doing great, the fever is gone, bellyache is gone and there’s no pain when they pee anymore, in your mind is that a kid that you should still change the antibiotic or is the clinical response more important than what you see in the lab?
And we won’t hold you to those and certainly again, on this program we want parents to listen to the advice of their doctors, but that’s one of the things that does come up sometimes.
Dr. Andrew Schwaderer: Yes. For me, what I do in that situation depends on how long they’ve been on the antibiotics. If the culture comes back and it’s about three days before I get the results that you mentioned and they’re doing better often I’ll just keep them on the treatment they were on. On the other hand, if it comes back very quickly I will switch them.
On another situation would be if the patients have recurrent urinary tract infection. If they’ve had one after another and after another then it might be even though it looks like they’re getting better the infection’s not going away. And in that situation I would definitely change the antibiotic as susceptible.
Dr. Mike Patrick: Sure. Great. So ultimately, it sorts of depends on what the reflux is causing in terms of harm to the child. So if they’re having recurrent urinary tract infections or if we start to see that there’s some kidney damage from the urinary tract infections and we’re going to talk about that in just a couple of minutes when we get to the complications discussion, but at some point you decide that things are bad enough that you do need to intervene surgically, how do you make that determination and what sort of surgical interventions are we talking about?
Dr. Rama Jayanthi: I think that the reason to consider surgery is if your medical management is failing, meaning that the child is continuing to have infections despite being on antibiotics, despite vigorously working with bladder and bowel habits, despite vigorously improving the child’s hygiene. If despite all these stuff the child continues to get infections then surgery, I think, is absolutely needed.
Dr. Mike Patrick: Sure. And what kind of procedure are our options?
Dr. Rama Jayanthi: Well there really are two options. The standard method of correcting reflux is a surgical procedure whereby one literally goes in to the bladder, one dissects the ureters and reattaches them within the bladder giving them the muscular support that they need.
Dr. Mike Patrick: So you kind of putting them in at an angle or a shallow angle so they traverse that muscle layer and not that right angle so they go right in.
Dr. Rama Jayanthi: Exactly. And that standard surgical procedure has a 99% chance of fixing the reflux once and for all.
Dr. Mike Patrick: Sure.
Dr. Rama Jayanthi: So it’s very effective.
Dr. Mike Patrick: And do kids tolerate that procedure pretty well?
Dr. Rama Jayanthi: They do. Most of the time the kids are in the hospital one night, maybe two nights. We now are even able to do that type of procedure laparoscopically so that one can often avoid making an incision.
Dr. Mike Patrick: Sure. And then you mentioned another treatment option.
Dr. Rama Jayanthi: Yeah. There is another option which is called ‘injection therapy’. With injection therapy one is not performing an actual surgery per se. With the child under anesthesia you look in to the bladder with the telescope and one looks at the opening of that ureter and injects a gel substance to try to create a valve mechanism.
Now this type of injection therapy is somewhat controversial at pediatric urology world because the success rates are not as high as with the standard surgical procedures. Often kids require several trips to the operating room before they are a success.
And lastly, the injection therapy tends to work best on the kids with the lowest degrees of reflux, the kids who most often don’t need surgery in the first place.
Dr. Mike Patrick: Sure. So this gel that you’re injecting it’s just you go in through the ureter into the bladder and then you’re injecting this into the tissue around that where the ureter enters into the bladder?
Dr. Rama Jayanthi: Exactly. Exactly.
Dr. Mike Patrick: Is this a material that would be there permanently or does it break down over time?
Dr. Rama Jayanthi: Over the course of time it does break down. It may take several years for that to happen, but it typically will break down over the course of time.
Dr. Mike Patrick: And once it breaks down then you could have the reflux come right back again?
Dr. Rama Jayanthi: It’s theoretically possible, but one way of looking at injection therapy is that you may be simply getting rid of reflux for a period of time to try to prevent infections until the child would have normally outgrown it anyway.
Dr. Mike Patrick: Gotcha. So really when you’re deciding between these two types of treatment you really have to take each kid individually and say what stage of life are they in, how bad was the reflux, how often are they getting urinary tract infections. And so this is really in individualized decision and why it’s important to have the expertise of a pediatric urologist who sees lots of kids with this problem to decide which path to take.
Dr. Rama Jayanthi: Absolutely. I think it’s a basic thing at pediatric medicine that you have to individualize treatment for the specific situation of the child.
Dr. Mike Patrick: Yeah. Which is why physicians are important and you can’t do vending machine medicine. It’s not a one size fits all in pediatrics for sure. Dr. Schwaderer, what complications can arise from recurrent urinary tract infections? So obviously, we’re treating this for a reason and one reason of course is that the infection that you mentioned can go to the bloodstream and they can be septic and that can be life endangering situation. But what about complications to the kidneys themselves from recurrent infection?
Dr. Andrew Schwaderer: So if the recurrent infections involve the kidney it can cause scarring of the kidney, which can cause high blood pressure. If the scarring of kidney involves enough of the kidney it can cause decreased kidney function. And certainly, many patients with reflux will do fine, will never have urinary tract infections, in fact, one out of five will probably never have a urinary tract infection. But there is a subset where it does involve the kidney, it involves the kidney repeatedly.
And if we look at our patients that need dialysis or a transplant when they’re child, the third leading cause is scarring from recurrent infections. So it is something that’s very important to recognize and then treat and get to the subspecialist if it recurs.
Dr. Mike Patrick: Sure. So this is something that can potentially be serious and can lead to kidney failure in some kids.
Dr. Andrew Schwaderer: In a small number of patients, correct.
Dr. Mike Patrick: Gotcha. We talked about renal ultrasounds as being one way to visualize the kidneys. There’s also a nuclear-type test that you can do. Talk about that a little bit.
Dr. Andrew Schwaderer: So the renal ultrasound is to look at the overall anatomy of the kidney and the bladder. The nuclear medicine test that you were looking at is something to look for scarring of the kidneys. So we can put a substance into the bloodstream that’s taken up a healthy kidney that’s not taken up a scarred kidney and use that to diagnose renal scarring.
Dr. Mike Patrick: Sure. One of the things that we really stress on this program is when deciding any kind of treatment for kids you got to look at the risk versus the benefit. And so I did want to talk a little bit about complications that can arise from the way that we treat these things.
So in terms of medical treatment of urinary tract infections obviously antibiotic creating a resistant bacteria can be an issue, but again the benefit that you get from not becoming septic and not scarring your kidneys is worth that risk. Correct?
Dr. Andrew Schwaderer: Correct.
Dr. Mike Patrick: Right. Allergic reactions are another possible risk that you could get from antibiotic use.
Dr. Andrew Schwaderer: Correct.
Dr. Mike Patrick: Other than that can you think of any other risks that would be an issues with the medical treatment of urinary tract infections?
Dr. Andrew Schwaderer: Some patients will get diarrhea, they’ll kill off the good bacteria in the GI tract and they can get some infections can be somewhat problematic. There’s something termed as C. diff, which you can get from chronic antibiotic use which causes a rather nasty diarrhea.
Dr. Mike Patrick: Yeah. So it’s good that parents know what risks are involved in our treatment, but at the end of the day the benefit from the antibiotics is going to outweigh the risks for this particular situation.
Dr. Andrew Schwaderer: It is. But it’s also important to make sure the antibiotics are given judiciously where they aren’t given when they aren’t needed and they aren’t given for longer period of times to minimize these complications that you were talking about.
Dr. Rama Jayanthi: And when we have a child on preventative antibiotics we typically don’t use strong antibiotics. The word I use to parents is ‘wimpy antibiotics’ that have been around for decades. We rarely would ever think about using a very strong potent antibiotic on a regular basis.
Dr. Mike Patrick: And I think that’s something that parents are probably very concerned about more so today than maybe 10, 15 years ago that because of our education on the judicious use of antibiotics that when parents hear my kid has taken antibiotic everyday that kind of raises a red flag I suspect in a lot of their minds.
Dr. Rama Jayanthi: Well absolutely.
Dr. Andrew Schwaderer: So I think when we use daily antibiotics it’s a bridge to get them to a more effective place. For instance, if they have constipation it might be something that’s helpful for the six to twelve months when the constipation is being resolved.
If they’re going to have surgery for reflux it’s something that can be given for a period of time until they are able to have the surgery. It’s usually not something they’re on for four, five, six years, I mean.
Dr. Mike Patrick: Yeah. And that’s something to and I’ve talked about this before on PediaCast, but in terms of constipation and its relationship to urinary tract infections as I understand it if the intestine is full of poop it’s pushing against the bladder, the brain gets the signal that the bladder is full when it might not be and so then they have this feeling like they have to go to the bathroom, but because the bladder wasn’t full it doesn’t empty completely and then you get that residual urine. Is that kind of the right thinking?
Dr. Andrew Schwaderer: Conceptually that’s how I would explain it as well.
Dr. Mike Patrick: Yeah.
Dr. Rama Jayanthi: Yeah. But there are many other factors. First of all, we use the word constipation all the time, but most of the kids we see may not necessarily be constipated. They may not be emptying their bowels completely. The child may be pooping every single day but they may not be emptying.
And the dilemma is in addition to any effect that that poop may have on bladder function that is a bacterial source. And if a child has all those poops sitting on the rectum the bacteria literally crawl out of the rectum and live by the perineum, live by the vagina, live by the urethra. And so that is where the infections come from, the child is infecting themselves.
Dr. Mike Patrick: It’s always kind of funny to me from a parent’s standpoint, the definition of constipation is infrequent hard bowel movements and from a medical standpoint, the definition of constipation is too much poop in the intestines that’s not moving.
Dr. Rama Jayanthi: Exactly.
Dr. Mike Patrick: Yeah. And then on the surgical side of things, what kind of complications can arise from surgical treatment that parents would need to be aware of?
Dr. Rama Jayanthi: Yeah. Fortunately, with reflux surgery the complications are pretty low. I said earlier that there’s 99% chance that the surgery will fix the problem once and for all. That means there can be 1% chance that something doesn’t heal properly, that the child may continue to have reflux despite the surgery or that there could be some type of obstruction that occurs from that reconstruction. But these types of complications are really relatively rare for reflux.
Dr. Mike Patrick: And of course with any surgical procedure you the risk of anesthesia, bleeding, infection, that sort of thing, but again, in a facility where they’re used to doing these procedures, so under professional hands those are pretty well minimized.
Dr. Rama Jayanthi: Exactly.
Dr. Mike Patrick: What is the long-term outlook of kids with this problem? Is this something that they typically outgrow and is it likely to come back when they’re an adult? Is this a lifelong thing they’re dealing with or is it pretty much just limited to childhood?
Dr. Rama Jayanthi: It’s pretty much limited to childhood as far as we can tell. What happens is that these kids can have lots of infections when they are young. Once the reflux is corrected that typically will prevent them from having kidney infections.
It’s important to realized though that the purpose of surgery for reflux is to help prevent kidney infections. The child may continue to have bladder infections after surgery because bladder infections have nothing to do with reflux.
Dr. Mike Patrick: Right.
Dr. Andrew Schwaderer: And then unfortunately, you can still have kidney infections even if you don’t have reflux. Certainly, it seems that if you have reflux it’s more likely for the bacteria to go from the bladder up into the kidney but there’s certainly a number of patients that don’t have reflux, we know that, and they still develop kidney infections, even recurrent kidney infections.
Dr. Mike Patrick: Right. And when we talk about long-term outlook, I guess the condition of the kidney when this problem finally is seeming to go away is an issue. So if you get through the reflux, the recurrent urinary tract infections and your kidneys come out OK that’s one thing. But if you do have kidney scarring and hypertension or high blood pressure or renal insufficiency or renal failure then obviously those are going to be long-term issues.
Dr. Andrew Schwaderer: Yes. Certainly, the patients that have scarring on their kidneys, particularly if it involves both kidneys would benefit from seeing a nephrologist to make sure that situations that could further impair kidney infection are limited.
Dr. Mike Patrick: Sure.
Dr. Rama Jayanthi: And there is one more long-term issue I’d like to just quickly mention. In the old days, it used to be felt that a young woman who could potentially become pregnant would have a much higher risk of complications of pregnancy is she was still having reflux.
And in the old days, that led to pediatric urologist suggesting that all girls had to have reflux corrected by the time they reach child-bearing age. Most would argue that that’s probably not the case. And so we have stopped doing surgery just because a girl is getting older.
Dr. Mike Patrick: It’s really more about the recurrent urinary tract infections.
Dr. Rama Jayanthi: Exactly.
Dr. Mike Patrick: Is there any way to prevent this from happening on the reflux side? Is there any way to prevent this? It’s really an anatomical issue, it’s developmental so there’s…
Dr. Rama Jayanthi: It is an anatomical issue but if a child is waiting too long before they urinate, if they have some bladder dysfunction, some abnormal bladder habits, that can cause reflux or that can make what should be trivial reflux into something more important.
Dr. Mike Patrick: Yeah. Because if the bladder is full then you have more pressure against that shallow muscle area that’s acting as a valve.
Dr. Rama Jayanthi: Exactly.
Dr. Mike Patrick: In terms of urinary tract infections themselves and we talked a little bit about this, promoting going regularly, good hygiene, taking care of constipation, those are all important to prevent urinary tract infections.
Dr. Andrew Schwaderer: Yes, certainly. We have many patients that have recurrent urinary tract infections and if they learn how to empty completely, to go to the bathroom at regular intervals, to get their bowel habits maximized so they aren’t having constipation often, the urinary tract infections will improve dramatically.
Dr. Mike Patrick: Great. What about cranberry juice? You always hear people talk about take cranberry juice to prevent urinary tract infections or to treat urinary tract infections. Is there any truth to that?
Dr. Andrew Schwaderer: There is some thought that there’s a substance in cranberry juice that can limit bacterial attaching to the wall of the bladder. It’s probably very sort evidence and it’s probably not harmful but it probably doesn’t do a great amount of help either.
Dr. Mike Patrick: Is it a sugar that supposedly does this, the sugar in cranberry juice or do we even know what?
Dr. Andrew Schwaderer: Yeah. There is a substance in cranberry juice. I forgot what it is, it’s actually at the top of my head.
Dr. Mike Patrick: Yeah. I mean it would have to be excreted in the urine to do that and you would think that any sugars would be digested and enter the bloodstream like any other sugars would be.
Dr. Rama Jayanthi: Yeah. I think there was one study in the geriatric population which suggested that cranberry juice could be helpful. I don’t think it’s ever been really recreated in a pediatric population. Plus, also it’s hard to find cranberry juice. If you go to a grocery store you’ll find cranberry juice cocktail or something which is ridiculously dilute.
Dr. Mike Patrick: Yeah. It’s mostly apple juice with like little flavorings.
Dr. Andrew Schwaderer: And in pediatrics with obesity epidemic we don’t like a lot of high sugar fluids given in copious amounts.
Dr. Mike Patrick: Great.
Dr. Rama Jayanthi: I wonder if I can add one more point here.
Dr. Mike Patrick: Absolutely.
Dr. Rama Jayanthi: I know, it’s funny I’m a urologist but I talk about poop all day long and a significant amount of our conversation today has been about bowels. But there’s another factor that’s incredibly important to preventing infections and that’s soap.
I know that parents are often told not to give your child a bubble bath because that could lead to infections and that concept has led to some being told not to clean their kids down below with soap and water and I think that that’s a mistake.
The bacteria that lead to infections literally live by the vagina and the urethra and so I always tell my parents to clean down there with soap and water on a daily basis to kill off those germs before they can crawl into the bladder.
Dr. Mike Patrick: Sure. And I think, at least in my own practice, when I do tell parents to avoid bubble baths it’s really just in the kids who seem to be sensitive to the soap, so you have kids who have recurrent where they complain that it hurts when they pee and you come in and check their urine and it’s normal and you find out they’ve been taking bubble baths so you think maybe they have a chemical urithritis.
But they can still wash with soap and water, they just need to rinse well and not be sitting in the soap for an hour because that’s what causes the irritation, but brief exposure to kill bacteria is certainly something that’s important.
Dr. Rama Jayanthi: Absolutely.
Dr. Mike Patrick: Great. Well I really appreciate both of you stopping by and talking about urinary tract infections and vesicoureteral reflux. For parents who are interested in more information about these things we do have some links in the Show Notes over at pediacast.org for episode 235.
The Nationwide Children’s Hospital Health Library has an article on pediatric urinary tract infections and vesicoureteral reflux. They’re kind of brief articles, kind of summation articles. We probably covered a lot more here than you’re going to find with those. But if you have family or friends who are interested or have a child with those conditions you may want to pass along those links.
If you’re interested in lots more information about these problems, Medscape has a couple of great articles on them and we’ll put links to those in the Show Notes as well so you can find out even more information if you are interested.
All right. So before you guys take off and especially with Christmas right around the corner, regular listeners of the show know that we talk about family games a lot just because we’re trying to get kids to do some things with the families or group that don’t necessarily involve video games and television screens, sort of more interactive stuff.
And so in keeping with tradition, I would just ask each of you, we’ll start with you, Dr. Schwaderer, what’s your favorite family game?
Dr. Andrew Schwaderer: It used to be Wii Sports with my kids. They’ve gotten to a point where they routinely beat me now though so it’s becoming less pleasurable to…
Dr. Mike Patrick: And I will say that that’s one exception to the ‘no screen rule’ because you’re being physically active and together as a family and interacting, so the Wii Sports stuff, but not so much now?
Dr. Andrew Schwaderer: They still love to play it but they’ve gotten to the point where they’re better than me.
Dr. Mike Patrick: Oh, got you. Yeah. Yeah. And Dr. Jayanthi?
Dr. Rama Jayanthi: My kids are all adults right now but when they were younger I think what we used to enjoy mostly we’re just playing soccer outside. I coached my kids when they were younger for years and we just love to do outdoors activities, being outside.
Dr. Mike Patrick: But now does it get to be too cold to do that here in Ohio?
Dr. Rama Jayanthi: It’s never too cold when you’re outside. It’s an attitude.
Dr. Mike Patrick: Got you. Got you. I love that! We always ask the guest about games and activities that you can do with your family and I sometimes get some emails that say ‘hey, what’s your favorite’ because I never really mention that on the show.
And so I sat down with my wife, we kind of put our heads together and looked at each age group and just thought back what were some of the things that or kids really enjoyed and if you’re thinking of Christmas ideas.
So we started out thinking OK babies and my wife and me said peek-a-boo. You just got your hands and kids always find that fun when they were really little. And for older babies I always like building blocks. Of course you have to make sure they’re not toxic and they’re made in a place maybe you trust. There’s no lead in the coloring, that sort of thing.
Just building blocks and then letting the baby push them over and knock them down and you’ll always get a giggle out of that, so building blocks. And then the toddler age, still building blocks, DUPLO blocks, Play-Doh, finger paint was always fun.
The preschool age, now when they can start to understand and play an interactive game with you and our favorites were Don’t Break the Ice, Cooties, Hi Ho! Cherry-O, although if you have a kid who is prone to putting things in their mouth you have to be careful with them choking because all these things have little pieces, but those were fun ones.
And then young school age, we loved Yahtzee and the LEGO games are kind of fun too. Creationaries one of them, Wild Wool. Do your kids enjoy LEGOs?
Dr. Andrew Schwaderer: My boys love LEGOs. They’re very into the theme LEGOs, the Star Wars and they’ve done a lot of really neat stuff recently. And we’re starting to play more mind games, like there’s one term Farkle where they learned how to add up certain…
Dr. Mike Patrick: Yeah. That’s a great one. Yeah.
Dr. Andrew Schwaderer: That they’ve really enjoyed in recent times
Dr. Mike Patrick: Yeah. And for the older school age kids, yeah Farkle, Five Crown is a card game that’s really fun and it’s a quick game, you can play a whole game in 20 minutes or so. So that’s a fun one. And of course Euchere, Canasta, we love card games at our house also.
And then the older kids, teenagers and young adults, few of our favorites Who? What? Where?. That’s a really fun one. It’s kind of like a Pictionary but you have to draw a person doing something in a certain place and so it’s more than just an object. You have to sort of draw a scene and then everyone has to guess what it is. That’s a fun one.
Things, then Settlers of Catan and Ticket to Ride. Have you heard of either those? Those are really fun. Dr. Spaeth, she’s a plastic surgeon here, she actually introduced and she’d mentioned it on the show about a year ago Settlers of Catan and I hadn’t heard of it up to that point. But she went on and on about she loved it and so we got that one for Christmas last year and we have won it out over the past year in our home. So that would be Settlers of Catan is what I recommend too.
All right. Well once again I want to thank both of you for stopping by. I really appreciate it.
Dr. Rama Jayanthi: Thanks for having us.
Dr. Andrew Schwaderer: Yes, thank you.
Dr. Mike Patrick: Great. I want to remind all our listeners out there, there’s no show next week. We’re going to be off for a vacation and we’re going to be preparing for Christmas, get our decorations and shopping and all that done. But we will be back in another show in a couple of weeks.
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And until next time, this is Dr. Mike saying stay safe, stay healthy and stay involved with your kids. So long everybody!
Announcer 2: This program is a production of Nationwide Children’s. Thanks for listening. We’ll see you next time on PediaCast.