What causes a urinary infection?
Urinary infection occurs when bacteria enter the the urinary tract via the bladder and multiply to cause an infection. In children, bacteria may move from the bladder to the kidney(s), as a result of ureterovesical reflux.
Is a urinary infection important or serious in children?
- Urinary infections can make children feel very ill with non-specific symptoms such as vomiting, abdominal pain and a high temperature
- Renal scarIf infection enters the kidney(s) by reflux, the infection may cause a scar to form in the kidney(s)
- Scarring of the kidney (pictured) due to infection is permanent. This can cause problems with kidney function and may cause high blood pressure in later life
- Urinary infections in children must be treated without delay to prevent scarring
- Urinary infections may be an indicator of problems (abnormalities) within the urinary tract. These abnormalities may be a risk factor for future problems, including further infections
How will I know if my child has a urinary infection?
Symptoms of urinary infection may vary considerably with age. Infection may occur without the “fishy” smell and burning pain which adults often experience. In babies and young infants, urinary infection often has very non-specific features. If your child has a temperature without any obvious reason (such as a cold or cough), you should try to collect a urine specimen so that infection can be ruled out.
Symptoms in infancy:
- High temperature (fever)
- Poor feeding
- Smelly nappies
- Abdominal pain (“tummy ache”)
Symptoms in childhood:
- High temperature (fever)
- Increased frequency of passing urine
- Vomiting and / or diarrhoea
- Being “off their food”
- Abdominal pain (“tummy ache”)
- Back pain
- Bed wetting (when previously dry)
- Smelly or bloody urine
- Pain when passing urine
How will a urinary infection be confirmed?
A sample of your child’s urine will need to be collected to look for signs of infection & dehydration. How the urine sample is collected will depend on your child’s age and how ill he/she is
The following headings describe the common ways in which urine can be collected from a child:
1. The older child who is toilet trained
a. Mid-stream urine (MSU) collection
- The child’s genitalia are cleaned with warm, soapy water
- The child begins to pass urine into the toilet
- Part way through passing urine, a specimen is collected into a sterile container
- The last part of the urine is then passed into the toilet again
2. The non-toilet trained child
a. “Clean catch collection” (preferred because of the low risk of contamination from skin or bowel motions)
- The child’s genitalia are cleaned with warm, soapy water
- Part way through passing urine, the collection is made in a container held under the child, without touching the child’s skin
b. Urine collection bagUrine collecton bag
- The child’s genitalia are cleaned with warm, soapy water and dried
- A special collection bag is stuck over the child’s urethral opening (“water passage”)
- As soon as urine enters the bag, the bag is promptly removed & the urine transferred into a sterile container
- If the collection is contaminated by bowel motions, the whole process must be started again
3. Very ill children (or those in whom it is difficult to catch a urine sample)
a. Specimen collection from a urinary catheter
- The child’s genitalia are cleaned with saline (salt solution)
- A small catheter is inserted into the bladder, through the urethra, by a doctor or nurse
- A specimen of the drained urine is collected in a sterile container
- The catheter is removed
b. Specimen collection from a suprapubic aspirateSuprapubic aspiration
- The skin in the lower part of the child’s abdomen (“tummy”) is cleaned with an antiseptic solution
- A fine needle is passed through the skin directly into the child’s bladder
- The aspirated urine is placed into a sterile container and the needle is removed
Collecting a urine sample from a child who is not toilet trained can be difficult and frustrating. Whilst using a collection bag may seem simple, this specimen is easily contaminated and the results are not as accurate as midstream or clean catch samples. Your Specialist Nurse, GP or Health Visitor can help you learn more about this.
How will my child’s urine infection be treated?
In babies and infants who are unwell, your doctor will not normally wait for the laboratory results to become available (this can take up to 48 hours) but will start treatment immediately with antibiotics. It may be necessary to change the antibiotic if your child is showing no improvement or if the laboratory results show that a different antibiotic would be better.
To clear the infection, it is very important that your child takes all the antibiotic medicine exactly as prescribed.
In most children, the fact that the child has improved is sufficient to say that the infection has cleared. In a few children (especially those with known abnormalities in the urinary tract), it is important that a further urine sample is collected and sent to the laboratory after the antibiotics have finished. This will confirm that the infection has been completely cleared. In these cases, it is best sent three days after the antibiotic course has been completed. If any traces of infection are found, the infection can come back again.
Will my child need further tests?
In a child over one year of age, additional investigations are not necessary unless the infections keep recurring or the bacteria found are unusual
It is normally recommended that children who have had a urinary infection before their first birthday should have an ultrasound scan of their kidneys, ureters and bladder. This is because a urinary infection can be the first clue to the presence of an underlying physical problem within the urinary tract. If any abnormality on the ultrasound is found, or if the infecting bacteria are unusual in any way, other tests and investigations may be needed
How can my child & I prevent further urinary infections?
- Ensure your child drinks plenty of fluids throughout the day so that he/she actually need to pass urine more frequently and the urine is lighter in colour (more dilute). Drinks should be water or water-based (e.g, squash) rather than tea/coffee/fizzy drinks
- Include a glass of cranberry juice in your child’s diet every day
- Ensure that your child goes to the toilet to empty his/her bladder regularly (e.g. on waking, mid-morning, lunch, mid-afternoon, teatime & before bed)
- Change nappies regularly
- Teach girls to wipe from front to back after passing urine so that germs from the anus do not enter the urethra
- Avoid scented soaps, bubble baths and hair washing with shampoo in the bath
- Encourage your child to wear only cotton underwear
- Ensure your child has a healthy diet
- Bio-yogurt may help by increasing “good bacteria”
- Constipation should be avoided. Ensure that your doctors are aware of any problems with constipation so that it can be treated immediately
- Follow the advice given to you about antibiotic treatment
Your doctors may decide that, to help prevent further infection, your child needs “prophylactic” antibiotics. This is a smaller dose than is used to treat an actual infection. It is intended to prevent infection from becoming established. Prophylactic antibiotics are best taken at bedtime.
What should I do if I think I have kidney stones?
If you have pain in your loin, especially if you also have other urinary symptoms or features suggesting an infection in your urine, you should contact your GP for further advice. Whilst kidney stones may cause pain in the loin with radiation down into your groin, there are many other causes for such pain. These include problems with your back and spine as well as a number of other non-urological conditions. The only way to find the cause of your symptoms is to have further investigations with your GP.
What are the facts about kidney stones?
- Kidney stones are found in 2-3% of people and 0.5% of people present each year with an acute episode of pain due to stones. These rates have been rising steadily since the start of the 20th century
- Men are more commonly affected than women. After the age of 50 when the sex distribution becomes equal
- At the age of 70, you have a lifetime risk of 1 in 8 for forming a stone
- Stones are responsible for more than 12,000 hospital admissions each year
- Stone formation is governed by both intrinsic (heredity, age & sex) and extrinsic factors (geography, climate, water intake & diet)
- Poor fluid intake combined with a low-roughage, high protein diet containing a lot of refined sugar increases the risk of forming stones
- There is an association with the “metabolic syndrome” (Syndrome X)
- Recurrence rates for stones are high (20% at 5 years, 35% at 10 years & 70% at 20 years)
What should I expect when I visit my GP?
1. A full history
Your GP will take a full clinical history, including asking about your diet, time spent in a hot dry climate, your fluid intake and whether there is a family history of stones.
2. A physical examination
A full physical examination, including assessment of your abdomen, will normally be performed and your blood pressure will be taken as part of the assessment.
3. Additional tests
The usual tests performed are:
a. General blood tests
The actual tests performed will be left to your GP’s discretion. It is normal to measure kidney function, liver function, blood sugar, uric acid, bone function (calcium levels) and to check the blood cells for anaemia or other problems
b. Urine tests
Your urine will normally be tested for blood (90% of patients with a stone have a trace of blood in the urine) and the pH (acidity) measured. A specimen may be sent to the laboratory to screen for infections and to measure a specific chemical called cystine. 24-hour urine output collections will also be arranged for more detailed chemical analysis If:
- you are less than 30 years old
- have a family history of stones
- have had stones within the previous 5 year
c. Other specific test
The best way to diagnose stones is to have a CT scan. Your GP may be able to arrange this for you. If not, he/she will arrange referral to a urology unit where the scan can be arranged. Almost all stones show up on a CT scan.
What could have caused my kidney stones?
The main reasons for forming stones are:
- Anatomical (structural) abnormalities (inherited or acquired)
- Excess stone-forming substances in the urine
- Lack of stone inhibitors in the urine
- Chronic Infection in the urine (mostly in post-menopausal women)
- Idiopathic (i.e. no reason identified in 5-10%)
In most patients, more than one of the groups above is involved in stone formation. Where no cause is identified, the stones are usually made of calcium oxalate. Recurrence of these stones is common. What treatments are available for this problem?
You will normally be given specific advice about changes to your diet and fluid intake which will reduce the risk of further stone formation. There is some evidence that stone inhibitor levels (especially citrate) can be increased by drinking fresh lemon juice in water. This reduces the levels of stone-forming chemicals in your urine. You should not restrict your calcium intake. Installing a water softener is not helpful in preventing further stones. Avoid grapefruit juice (pictured) and vitamin C supplements which can increase the risk of forming stones. Medical treatment Thiazide diuretics and other drugs may be used to reduce the calcium levels in your urine. It may be possible to dissolve certain less common types of stone using drugs but this is only appropriate for
- cystine stones (penicillamine therapy)
- uric acid stones (urinary alkalinisation)
If you have a stone caused by infection, you will be prescribed antibiotics before stone treatment and you may be asked to continue them after surgery. You may be given further advice about specific medical treatment once your stone has been analysed chemically.
Small, symptomless stones in the kidney can be monitored by regular checks with an X-ray. Stones of a similar size in the ureter (less than 5mm diameter) may pass by themselves but active treatment will normally be recommended if the stone shows no sign of passage after 2-3 weeks. If you are found to have a stone in the ureter, you may be prescribed a muscle-relaxant drug (usually an alpha-blocker, normally used to relieve prostate symptoms). This can help to speed stone passage by specifically relaxing the muscle of the ureter. Drugs which relieve muscle spasm (e.g.Buscopan, Probanthine) are still used but have little effect on symptoms and do not speed stone passage.
This is the most common treatment recommended for stones in the kidneys and for stones less than 1cm diameter in the upper ureter (the drainage tube between kidney & bladder). 90% of stones will clear with one treatment but some patients may need re-treatment or even surgical intervention. If your stone has not responded to two successive treatments with ESWL, it is unlikely to fragment with further treatments. Other removal methods will then be considered. ESWL cannot be performed safely in
- pregnant women
- patients on heparin, Warfarin or other blood-thinning agents (e.g. dipyridamole, clopidogrel)
- patients whose weight exceeds 300lb.
The main reasons for recommending surgical treatment are:
- a stone which is too large to pass spontaneously (greater than 5mm diameter)
- a stone which is causing obstruction to urine drainage
- a stone which is causing (or has been caused by) infection
- a stone which has formed as a result of an anatomical (structural) problem which also needs correction at the same time as stone treatment
- failure of simple painkillers to control symptoms
Percutaneous (keyhole) surgery
This is used for large stones in the kidney (e.g. “staghorn” stones) or large stones in the upper ureter, either as a primary measure or if ESWL has failed.
Smaller stones in the kidney can be extracted or fragmented with a laser, using a flexible telescope passed through your bladder. You may have a temporary stent inserted after this procedure.
Stones in the ureter can be extracted or fragmented with a laser, using a rigid telescope passed through your bladder. You may have a temporary stent inserted after this procedure. Courtesy Endourology Patras
Insertion of a ureteric stent
In the emergency situation, when a stone is blocking the ureter completely, it may be necessary to insert a stent under general anaesthetic to relieve the blockage so that definitive treatment can be performed at a later stage. Courtesy Nigel Bullock
If there is a blockage with severe infection due to a stone in the ureter, a drainage tube may be inserted into your kidney under local anaesthetic to relieve the problem. This will be followed, at a later date, by definitive treatment of the stone. Credit http://www.baus.org.uk/patients/symptoms/index
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