UTI, urinary tract infection

UTI, or urinary tract infection, refers to infection of the urinary tract. Such an infection may be localized to the urethra (urethritis), the bladder (cystitis), or the kidneys and upper collecting system (pyelonephritis). The infection is usually bacterial but in the case of the bladder can be (much less commonly) viral.

UTI is much more common in girls than boys. Among boys, UTI is much more common in uncircumcised boys (10 to 20 times more likely). In fact, a UTI in an uncircumcised boy is considered by many doctors to warrant studies for internal urinary tract abnormalities, especially a condition called posterior urethral valves.

In girls, the major causes of urinary tract infection are

poor hygiene in young girls - usually poor wiping technique (see below)
constipation, leading to urine holding and poor urinary outflow
problems of internal urine tube function - VUR or vesicoureteral reflux - which means that bladder urine flows back up the ureter (the tube from the kidney to the bladder), carrying bacteria to infect the upper tract (ordinarily, any bacteria that enter the bladder from the outside world through the urethra are flushed out again with the next urination - hence the advice for girls to drink proper amounts of fluid and urinate every couple of hours)

Girls are not born knowing how to wipe properly after urination. They must be taught. Proper wiping is "front to back, and drop the paper," meaning to stress that the child should always wipe down and never up, or up-and-down.

A good history for the investigation and treatment of UTI should include some questions about bowel habits. Parents are often unaware of their children's bowel habits once they reach the age when they no longer need help to wipe their bottoms after a movement. Infrequent large or hard stools can interfere with normal bladder emptying during urination and lead to UTI.

I was taught that any infection in a girl under two, or two or more infections in any girl should prompt urinary tract studies to detect vesicoureteral reflux: an abdominal ultrasound, perhaps a bladder xray (voiding cystogram), or even an isotope tracer study. This is because this type of malfunction of the urine collecting system really has no other symptoms besides infection, but undetected can lead to significant damage to the kidneys and even eventual kidney failure and the need for kidney transplantation.

Diagnosis

Urinary tract infection is diagnosed by symptoms and laboratory tests. Pain with urination (dysuria), cloudy and sometimes "strong" smelling urine are common complaints. Tenderness to pressure over the bladder is very suggestive of infection; tenderness to tapping over the kidneys is suggestive of kidney involvement, which is more serious than a simple bladder infection. A simple dipstick urine test in the doctor's office can suggest infection, but in children should not be relied upon. The "gold standard" of diagnosis is an overnight incubation of the urine to detect the presence of abnormal numbers of bacteria. E. coli is the most common causative bacteria for urinary tract infection. Remember that connection between wiping and infection - E. coli is a stool germ. If bacteria are detected in the urine at a level to suggest infection, further tests are performed on the isolated germ to determine what antibiotic choices are best for the specific infecting bacteria. Urine specimens can be obtained by "clean catch," or by catheterization of the bladder. (In very small infants, it is sometimes necessary to tap the bladder with a syringe and needle.)

Treatment

Treatment of UTI includes antibiotics, usually by mouth unless the child is very young, "sick" (high fever or vomiting), or significant kidney involvement is suspected. In such cases, hospitalization and intravenous antibiotics may be necessary. Increased fluid intake, by mouth or by vein if necessary, is also helpful to "flush out" the infection. The goal of treatment is to sterilize the urinary tract as quickly as possible, to prevent progression of the infection and damage to the kidneys with susequent kidney scarring.

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