PEDIATRIC UROLOGY DMSA Scan Findings in Children with Febrile UTIs

David T. Bolong, MD o DMSA Scan abnormalities in 50-80%

February 4, 2014 o VUR in only 32-40% of patients with abnormal
DMSA Scans
INTRODUCTION o When VUR present, 80-90% demonstrated
1-2 % will have congenital anomalies. 70% of those DMSA scan abnormalities, including almost all
congenital anomalies are of urologic origin. with Grade III-V VUR.
Most common o Why should we get this?
o Hernia When you have a patient that presents with
o Undescended testes UTI but you are not convinced or are not
sure that there is a UTI. Ask for this and you
Common Urologic Problems: will be able to determine the degree of
Urinary tract infection scarring via this parameter.
Voiding Dysfunctions Evaluation of children with UTI
Antenatal/ Postnatal hydronephrosis o History (emphasis on):
Abdominal masses Number of UTIs - febrile or afebrile presence
Painful scrotum of voiding disorders such as
Empty scrotum daytime/nighttime wetting, urgency,
Anomalies of the external genitalia Concomitant incontinence, dysuria
findings with Anorectal Malformations Constipation
Siblings with UTI
Urinary Tract Infection Past surgeries especially at the anorectal
Definition: Any number of colonies obtained by area
suprapubic bladder tap. Neurologic problems
o Place a needle in the urine and catch the urine. It
is difficult to collect a midstream catch urine in a Physical Examination
young girl or boy Is phimosis a normal finding in newborns? YES!
o This is not done in children. The closest that we The usual prepuce in children is as small as 1.5 mm
do is a urinary catheterization. o Examine the prepuce, hold it by the side and look
In children, the younger they are the higher the inside.
chances of renal damage as compared to adults. o Physiologic phimosis until the age of 11 when
o 1 year old or 6 years old with UTI, you have to we should be able to pull the prepuce away from
make sure that there will be no kidney damage. the glans penis.
o Just make sure you work up the patients as much Vulvar synechiae
as possible. o Before and after treatment:
Younger Congenital anomalies, foreskin Treatment: topical estrogen
Most common cause of UTI: Sexual intercourse! o Make sure that there is an anal orifice
Middle age Functional Voiding Disorders Examine the back
Older STI o Dimple at the lumbosacral area with recurrent
Why early evaluation is necessary for all infants and UTI neurogenic bladder
young children: Verify by ultrasound that shows thickened
o Recurrence in 30-40% bladder
o High incidence of VUR-35% o Assess for the possibility of spina bifida when you
o Clinical parameters unreliable in detecting those see dimpling. Check for neurologic deficits. There
with VUR may be a myelomeningocele
o Infants at highest risk of pyelonephritis and renal
scarring Work-up
o Higher incidence of scarring with RUTI Thorough History Taking
Basic Treatment Tenet: Must be a proven UTI! Physical Examination
Proper collection of urine is the cornerstone of Urinalysis (Properly Done)
treatment. o Never accept a collection from wee bag as a UTI.
o Infants below one year of age, a suprapubic tap The urine should be properly collected. The
is recommended. proper collection is catheterization, the gold
o A catheterized urine is a good alternative to standard is suprapubic which cannot be done
obtain urine specimen. KUB Ultrasound
o A midstream collection is acceptable for o To rule out congenital anomalies
cooperative children. Voiding Cystourethrography (VCUG)
Proving UTI by urinalysis: o Graded according to severity
o Gram staining an uncentrifuged urine has a Low grade can go away in time
sensitivity of 93% and a false + of 5%. High grade requires intervention
o Urine dipstick has a sensitivity of 88% in the Renal Scan (DMSA scan) see above!
presence of leucocyte esterase or nitrite and a
false + rate of 4%. Indications for both UTZ and VCG
o Pyuria alone has low true positive rate and high o For all children < 5 years old with first UTI
false positive rate. o School-age girls with firs febrile UTI.
For >5/hpf: TPR.67/FPR,21; o School-age and adolescent boys with first febrile
For >10: TPR .77/FPR.11 UTI
Risk Factors for UTI. Indications of UTZ only (VCUG or Renal scan if
o Female sonogram is abnormal):
o Below 5 years old o School-age boys with first afebrile UTI
o Vesicoureteral reflux o School-age girls with recurrent cystitis
o Voiding dysfunction o Adolescent girls with first febrile UTI.
o Constipation
o Obstruction VESICOURETERAL REFLUX
o Toilet training
o Sexual activity Primary Vesicoureteral Reflux
o Pregnancy Bumabalik ang ihi
Associated problems seen with UTI: Pediatric Urology Most common cause: orifice that is displaced.
Database 4201 cases (1995-present) Normal orifice: Ureter passes through the bladder in a
o Anatomic anomalies19% tangential manner, goes below the mucosa and has
o Vesicoureteral reflux34% an opening.
o Voiding Dysfunction 40% They pee with the pressure of the bladder pressed
o Idiopathic. 25% against the intramural portion one way valve

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Secondary Vericourethral Reflux
No intramural portion, the pressure of the bladder
goes up
Should not be corrected immediately especially for
low grade since they would regress
o Refluxes should not be corrected
immediately!
Management
Daily antibiotic prophylaxis
o Does not affect children even as long as 5 years,
so its ok to give antibiotics long term provided its
low dose
Regular volitional voiding
In children with unstable bladder: anticholinergics+
timed voiding+ pelvic floor exercises
Manage constipation
Periodic urinalysis-suspect-culture/treat
VUR follow-up and upper tract assessment
Principle of medical management of patients with VUR
40-60% recurrence of UTI in 18 months
If with scarring, likely to get worse with every UTI
Most mild to moderate VUR resolve spontaneously
Pelvic floor Exercise program
Patients with VUR.. 30% Enuresis
Indication: UTI, overactive bladder, bladder-sphincter
discoordination
18 patients had a minimum 1 year follow-up: 8
patients cured (44%), 6 patients partial response
(33%), 4 patients no response (22%)
Without VUR- 13
Indications: overactive bladder in 16, Bladder
sphincter discoordination in 4, bedwetting in 2
10 had a one year minimum follow-up
Response: 7 had good response (70%), 3 partial
response (30%)
VOIDING DISORDERS
Normal: Bladder contracts and sphincter relaxes and
vice versa. The sphincter is closed at all times. But
there is a voluntary sphincter which we relax to empty
the bladder.
o Males stand still and females sit down to relax the
pelvic floor.
o Peeing allows it to open and allows the bladder to
contract. It should be done together. Your
sphincter does not open just because the bladder
contracts.
Peeing is frequent in younger children because the
capacity is small.
st
Uncoordinated voiding is common in the 1 year of
life
As the child grows older, he/she leans to control by
first squeezing the sphincter- this forces the bladder to
accommodate a bigger volume
In time they can urinate at will.
Voiding dysfunction basically is when the bladder
does not enlarge at all or the child does not develop
proper control of voiding.
Children especially females UTI is usually due to
voiding disorders
Dysfunctional Voiding
o The child did not learn how to relax the sphincter
Constipation
Many children with recurrent UTI has constipation
o The bladder and the rectum both come from the
cloaca
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o They just divided via the urogenital septum.
Rectum is distended, bladder does not contract well
and the rectum and bladder has the same embryonic
origin
Rome II definition of Constipation:
o Two or more of the following symptoms present
for a total of at least 12 weeks in the preceeding
year:
Straining in more than 25% of defecations
Lumpy or hard stools in more than 25% of
defecations
Sensation of incomplete evacuation in more
than 25% of defecations
Sensation of anorectal obstruction in more
than 25% of defecations
Use of manual maneuvers to facilitate more
25% of defecations
Fewer than 3 defecations per week.
Constipation:
o Increased post void residual.
o Pressure of stool on the bladder causes:
Reduced functional capacity
Stimulation of stretch receptors triggers
overactivity
o Functional Discoordination of the anal sphincter
(and also the external urethral sphincter)
Amongst constipated patients,53%
contracted instead of relaxed the ext. anal
sphincter and PF during defecation attempts.
Treatment of constipation leads to remarkable
improvement of incontinence and UTI.
Dysfunctional Elimination syndrome
Urinary incontinence
Fecal incontinence
o They originate from the cloaca and are closely
related to each other.
A problem in one easily affects the other
Recurrent UTI
Monosymptomatic Nocturnal Enuresis
Persistent Nocturnal Enuresis
Bedwetting
Most common cause of enuresis in children:
Nocturnal polyuria
o Newborns dont have ADH (some until 10 years
old)
o Thus, there is enuresis
Most common cause of enuresis in adults: (not
mentioned)
o Adults only pass out 30% of the urine output at
night due to the secretion of ADH
Abdominal mass
< 1 year old with mass
o Most common cause is the kidney (80%)
At 2 years old
o Caused by solid organs: hepatoblastoma and etc.
Hydronephrosis
Not all hydronephrotic kidneys in children are
obstructed. Some are born with hydronephrosis which
is a normal physiologic variant and can correct itself
o Reflux can also cause hydronephrosis but can
correct itself.
Most common cause: Ureteropelvic junction
obstruction
Distinguish hydronephrosis in children which are non-
functioning
o Prenatally diagnosed MCKD
Uretopelvic junction obstruction
Mickey Mouse Sign
Can correct itself
Still has function
Multicystic Dysplastic Kidney
Did not develop into a kidney only
cysts
No need to salvage this; they regress in
time.
o Determined by doing a renal scan
Prenatal hydronephrosis EXTERNAL GENITALIA: THE EMPTY SCROTUM
Will resolve spontaneously Undescended Testis
Wait until mother gives birth because its the placenta Retractile Testis
that is responsible for the role of the kidney except in Ectopic Testis
oligohydramnios, in which prenatal intervention does Impalpable Testis
not work) Cryptorchidism Age-related effect on the gonocyte
Majority: number
o Unilateral with normal contralateral kidney Age 2 shows drop in total number of germ
o Evaluation: ultrasound at 3-4 weeks cells.
Bilateral Age 3: 1/3 normal, 1/3 diminished, 1/3
o Require prompt evaluation markedly diminished germ cell count
VCUG, Ultrasound prior to discharge The higher the level of the testis , the greater
o Treatment of valves, obstructive, ureterocele the effect on the germ cell
o Antibiotic prophylaxis non-obstructive lesions By puberty, 90% reduction in the germ cell
Clinical Indications for Surgery count in the abdominal testis.
o Declining relative renal function Age and infertility
o Febrile Urinary Tract Infection Early orchidopexy ( 2y/0) is associated with higher
o Well-documented worsening of urinary drainage inhibin and lower FSH: Early orchidopexy is
beneficial
MASSES FROM THE KIDNEY Malignant Tendency
AAP- Committee on External Genitalia:
Wilms Tumor Strongly recommend orchidopexy at one year of age
Most common renal mass from the children as optimal
Must be distinguished from neuroblastoma
o They are distinguished by origin, WILMS Empty Scrotum
Kidney Undescended Testis (1-2%)
Ask for urine VMA neuroblastoma o Wait for about 9 months before deciding to
(catecholamine products) operate
o 80-90% of neonatal masses are renal in origin o Human testes 32 degrees centigrade
o Ureteropelvic junction obstruction is the most o More prone to cancer formation
common cause, followed by the MCKD Retractile Testis
They come with recognized syndrome (overgrowth o Due to cremasteric muscles.
syndrome) when you see this in a child, investigate o Contraction of cremasteric muscles hides the
for Wilms Tumor testis
Non-overgrowth syndromes o To distinguish it, milk the testis and bring it down
o Aniridia and it springs back undescended. If it stays
o WAGR (WT, aniridia, genitor down, it is aretractile.
o Denys-Drash syndrome Ectopic Testis
o Bloom syndrome Impalpable testes
Develops renal failure since the kidneys are
not working well. Normal penis of a newborn is 2.64 +/- .26 cm (first SD)

External Genitalia (Painful Scrotum) Buried penis just push the fat.
Testicular torsion
Torsion of appendix testis Anything smaller, consider as micropenis
Epididydymitis / Orchitis Important to diagnose because they are treatable
Incarcerated hernia

Torsion Testicular Appendages
Physical exam Why is it the basic rule that we have to treat hernia?
o Mild scrotal erythema The younger they are with an hernia, they must be
o (+) cremasteric reflex treated.
o Localized tenderness Once intestines becomes encarcerated necrosis
o blue dot sign
o Findings less specific later in course Hydroceles Water in scrotum
Differentiate from epididymoorchitis in children if Wait for 18 months before operating because they
not sure, operate. If you have ultrasound they can be usually regress.
differentiated by Doppler Ultrasound (Flow)
Epididymitis secondary to an ectopic ureter to the vas Testicular malignancy
deferens Yolk sac carcinomas high AFP
o Epididymitis- most common: sexual
experimentation with a promiscus woman Varicoceles
Key mgt: Doppler US Large veins
Trauma to the testis Not operated on all the time.
They are operated when it causes unrelenting pain or
Acute Scrotum: Henoch Scholein Purpura when testes becomes smaller
Systemic vasculitis skin, joints, GI, GU o Varicocele carries warm blood.
Nonthrombocytopenic purpura
Purpuric skin lesion Anomalies of external genitalia
2-30% scrotal findings Hypospadias
Normal color doppler US o Most common
RX: steroids/expectant Ventral delay
Chordee proximal located meatus
Acute scrotum: Idiopathic Scrotal Edema Prepuce in the ventral portion did not
Scrotal edema, erythema: develop
Prepubertal boys, waddling gate Scrotum transpositions scrotum goes up
Testis +/- palpable, but nontender
Normal color doppler flow
Resolve in 49-72hrs Ambiguous Genitalia do karyotyping!
Bug bite, allergic reaction, cellulitis

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