Suprapubic aspiration of the bladder. Perforation of a viscus other than the bladder

[Urinary tract infections in children]

Urinary tract infections (UTI) are the most common bacterial infections in children. The symptoms are not very specific and range from abdominal pain, poor feeding to nocturnal urinary incontinence. The technique of collecting urine plays an important role for securing the diagnosis. The best way to obtain urine in non-toilet-trained children is catheterization or suprapubic bladder aspiration. In toilet-trained children midstream urine is an acceptable alternative after cleaning the foreskin or labia. In the case of an infection a prompt empirical antibiotic therapy is necessary to reduce the risk of parenchymal scarring of the kidneys. There are different approaches to diagnose vesicoureteral reflux in different countries. The commonly used standard approach in Germany is voiding cystourethrography. In the case of reflux dimercaptosuccinic acid (DMSA) scintigraphy should be performed additionally to exclude renal scarring (bottom-up approach).

Success rate of BladderScan-assisted suprapubic aspiration

OBJECTIVE

Suprapubic aspiration (SPA) is the gold standard for obtaining uncontaminated urine specimens in young febrile children. The use of real-time ultrasound (RTUS) has been shown to increase the success rate of SPA. The BladderScan (BSUS) Verathon(®) is an alternative portable ultrasound device designed to provide automated measurement of bladder volume. Although simple and requiring minimal training, there are no data on the success rate of SPA using the device.

METHODS

An audit of current SPA practice using BSUS in the ED of a tertiary referral children's hospital was conducted. We assessed the success rate of SPA to obtain urine and correlate with BSUS readings and techniques.

RESULTS

Sixty SPAs (mean age 5.0 months) were observed over an 8-month period between August 2009 and March 2010. The audit showed an overall success rate of 53% (32/60) [95% confidence interval 41-66%]. Success rates were 63%, 32%, 82% and 63% for the largest BSUS readings of 0-9 mL (n = 8), 10-19 mL (n = 25), 20-29 mL (n = 11) and 30+ mL (n = 16), respectively, or 39% at <20 mL and 70% at ≥20 mL (P = 0.02).

CONCLUSION

The success rate of SPA in 'real-life' non-standardised clinical practice was low at 53% overall. The BSUS-assisted SPA success rate was higher in patients with readings ≥20 mL. These rates are lower than success rates reported using RTUS. Parameters for using BSUS to assist SPA should be established.

Assessing bladder volumes in young children prior to instrumentation: accuracy of an automated ultrasound device compared to real-time ultrasound

OBJECTIVES

Automated bladder ultrasound (ABUS) devices are portable and designed to provide automated measurement of bladder volume. They are simple and require minimal training compared to conventional real-time ultrasound (RTUS). Their most common application in the acute pediatric setting is to assess bladder volumes prior to performing invasive urine collection such as suprapubic aspiration (SPA) in children younger than 2 years of age. However, data on ABUS in young children are limited. The aim of this study was to assess the repeatability and accuracy of one type of ABUS, the BladderScan, in measuring of bladder volume in children aged 0 to 24 months when compared with RTUS.

METHODS

Healthy children aged 24 months and younger were scanned twice, 1 hour apart, using ABUS and RTUS. ABUS readings were performed by two senior pediatric emergency physicians who both completed three readings for each child. The measurements were repeated using a second ABUS machine in case of machine variability. RTUS measurements were performed by a pediatric sonographer who was blinded to the ABUS results. ABUS and RTUS measurements were compared by Bland-Altman analysis to determine the repeatability coefficient (repeatability) and the limits of clinical agreement (accuracy).

RESULTS

Bladder volume measurements were performed on 61 children aged 0 to 24 months (31 males; mean ± SD = age 11 ± 6.2 months; range = 0 to 24 months) using both the ABUS and the RTUS. There was wide variation between ABUS and RTUS measurements. The repeatability coefficient within ABUS readings was 20 mL. By Bland-Altman analysis, the 95% limits of agreement between ABUS and RTUS were -31 to +19 mL. ABUS also detected no values between 0 and 10 mL.

CONCLUSIONS

This study showed poor repeatability and accuracy in bladder volume measurements using BladderScan ABUS when compared to RTUS. The ABUS method does not appear to be a reliable method for assessing bladder volumes in children aged 0 to 24 months prior to bladder instrumentation.

Urinary tract infections in children younger than 5 years of age: epidemiology, diagnosis, treatment, outcomes and prevention

Although the true incidence of urinary tract infections (UTIs) in children is difficult to estimate, they are one of the most common bacterial infections seen by clinicians who care for young children. Except for the first 8 to 12 weeks of life, when infection of the urinary tact may be secondary to a haematogenous source, UTI is believed to arise by the ascending route after entry of bacteria via the urethra. Enterobacteriaceae are the most common organisms isolated from uncomplicated UTI. Infection with Staphylococcus aureus is rare in children without in-dwelling catheters or other sources of infection, and coagulase-negative staphylococci and Candida spp. are associated with infections after instrumentation of the urinary tract. The diagnosis of UTI in young children is important as it is a marker for urinary tract abnormalities and, in the newborn, may be associated with bacteraemia. Early diagnosis is critical to preserve renal function of the growing kidney. A urine specimen for culture is necessary to document a UTI in a young child. Prior to culture, urinalysis may be useful to detect findings supporting a presumptive diagnosis of UTI. The goals of the management of UTI in a young child are: (i) prompt diagnosis of concomitant bacteraemia or meningitis, particularly in the infant; (ii) prevention of progressive renal disease by prompt eradication of the bacterial pathogen, identification of abnormalities of the urinary tract and prevention of recurrent infections; and (iii) resolution of the acute symptoms of the infection. Delay in initiation of the antibacterial therapy is associated with an increased risk of renal scarring. The initial choice of antibacterial therapy is based on the knowledge of the predominant pathogens in the patient's age group, antibacterial sensitivity patterns in the practice area, the clinical status of the patient and the opportunity for close follow-up. Imaging studies to detect congenital or acquired abnormalities are recommended following the first UTI in all children aged <6 years. Patients with significant urinary tract abnormalities and/or frequent symptomatic UTI may benefit from prophylactic antibacterials. The main long term consequence of UTI is renal scarring which may lead to hypertension and end-stage renal disease. Prevention of recurrent UTI focuses on detection, and correction if possible, of urinary tract abnormalities. Interventions that have been associated with a decrease in symptomatic UTI in children with a history of recurrent UTI include relief of constipation and voiding dysfunction.

Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates

STUDY OBJECTIVE

To compare success rates, complications, and efficiency of suprapubic bladder aspiration with urethral catheterization in ill infants.

DESIGN

Prospective, randomized clinical study.

SETTING

The pediatric emergency department at the University of Mississippi Medical Center in Jackson.

PARTICIPANTS

Convenience sample of infants under 6 months of age requiring an uncontaminated urine specimen for the evaluation of febrile illness, suspected urinary tract infection, or sepsis. Infants with wet diapers were excluded.

INTERVENTIONS

Patients were randomized to undergo timed suprapubic bladder aspiration (performed by a physician and a nurse) or urethral catheterization (performed by two nurses). If suprapubic bladder aspiration was unsuccessful, urethral catheterization was performed immediately and the bladder was drained; emptying volume was recorded. All patients had a next-void "bag" urinalysis performed for post-procedure hematuria.

RESULTS

Fifty patients underwent primary suprapubic bladder aspiration. The success rate (defined by obtaining at least 2 mL of urine) was 46%. Mean +/- SD time per successful suprapubic bladder aspiration was 16.73 +/- 7.73 seconds. Fifty patients underwent primary urethral catheterization. The success rate was 100%; the mean time required was 80.70 +/- 46.52 seconds. After failed suprapubic bladder aspiration, urethral catheterization was 100% successful, with a mean draining volume of 2.95 +/- 2.38 mL. No immediate problems were identified among any instrumented patients; later complications (next-void hematuria after either procedure, other visceral injury with suprapubic bladder aspiration) were not detected.

CONCLUSION

Both suprapubic bladder aspiration and urethral catheterization afford the emergency physician low-risk access to uncontaminated urine in ill infants. Suprapubic bladder aspiration is less efficient in that it requires physician participation and failure rates are higher. These data suggest that successful suprapubic bladder aspiration is primarily dependent on the volume of urine in the bladder; thus, in the ill or febrile ED infant who may be dehydrated, the likelihood of success decreases. The authors recommend that ED nursing and physician staff become comfortable with performing urethral catheterization on infants.

Massive hemoperitoneum following suprapubic bladder aspiration

Hemoperitoneum in the newborn is usually a result of visceral injury from birth trauma. This report describes an as yet unreported complication of massive hemoperitoneum following suprapubic bladder aspiration.

Suprapubic bladder puncture in a private pediatric practice

Suprapubic bladder puncture was performed 185 times in 126 girls in a private pediatric practice. Cultures of urine obtained by aspiration confirmed symptoms as indicative of urinary tract infection in 59% of instances and confirmed positive cultures of urine obtained by voiding in 57% of instances. Since suprapubic bladder puncture avoids the problem of contamination, it enables a certainty in diagnosis that voided specimens cannot. The procedure was easily accomplished in the office and was readily accepted by parent and child. No complications were observed.

Urine culture in the evaluation of suspected neonatal sepsis

Clinical records of patients in a neonatal intensive care unit were reviewed to determine the efficacy of obtaining a urine culture in the detection of neonatal sepsis. During a 12-month period, 188 sets of concomitant blood and urine cultures were obtained in infants less than 72 hours of age (early onset group) and 189 sets of cultures in infants over 72 hours of age (late onset group). Blood cultures were positive in nine instances in the early onset group and 11 instances in the late onset group. All but one blood culture in each group was accompanied by a negative urine culture. Urine cultures alone were positive in two instances in the early onset group and 13 instances in the late onset group (P less than 0.05). Symptoms did not differentiate infants with bacteremia from infants with bacteruria. Culture of the urine was shown to be necessary for the detection of a significant number of late onset infections. Urine culture in the early onset age group had a significantly lower yield, and the risk of suprapubic bladder tap in this group may not be justified.

Is there bacteremia after suprapubic aspiration in children with urinary tract infections?

It has been shown that bacteremia may occur after bladder puncture in animals. Whether this also happens in man is not known. Thirty-three patients who were suspected to have urinary tract infection were examined for bacteremia after suprapubic bladder puncture. Of these children 19 had infection. There was no positive blood culture in any of these cases after suprapubic bladder puncture.

Neonatal urinary tract infection with petechiae and thrombocytopenia

Thrombocytopenia and petechiae were signs of urinary tract infection in 2 neonates. Both infants had significant anomalies of the urinary tract. In each case antimicrobial therapy eliminated the infection and thrombocytopenia, allowing the surgical correction to be performed when the infants were clinically well. The importance of urine cultures and excretory urography in such cases is emphasized.

Suprapubic micturition cystourethrography in infancy and childhood

Suprapubic bladder puncture has recently found additional employment in paediatric radiology as a technique for micturition cystourethrography. Experience of 247 micturition cystourethrographies (MCU) by means of suprapubic bladder puncture (SBP) in 210 children aged from 6 days to 15 years is reported. The technique is simple: complications were observed in 6%, but were harmless in nature. The advantages consist in the absolutely sterile procedure, less strain on the children, and the possibility of simultaneously obtaining bladder urine, directly, for bacteriological and cytological examination.

Diagnostic needle aspiration in pediatric practice. With special reference to lungs, middle ear, urinary bladder, and amniotic cavity

Effective antibiotics are now available for most of the common bacterial infections. However, with few exceptions they are limited in their spectrum of activity and some have significant toxicity. In order to provide rational therapy, the physician must have knowledge of the infecting organism. The pediatrician is at a particular disadvantage in obtaining specific etiologic information since his young patient is often unable to cooperate or volunteer materials. In the critically ill child, every effort should be made to obtain material from blood and from the focus of infection. Indirect cultures such as those of materials from the nose and throat frequently yield confusing results as to the etiology of lower respiratory tract infection and of otitis media. Needle aspiration of material from the infected focus provides material directly pertinent to the etiologic agent for immediate and definitive diagnosis. Lung punctures and aspiration of middle ear fluids and bladder urine are discussed as examples of useful application of the techniques of needle aspiration. The pediatrician should become familiar with these techniques and use them where applicable.

Urinary infection in two selected neonatal populations

The urines from 204 infants admitted to a neonatal special care unit and from 25 infants whose mothers had bacteriuria in the last trimester of pregnancy were cultured and examined for white cells. A comparison of 39 bag collected urines with suprapubic specimens showed that growth in a bag collection was usually due to contamination, and that the presence of more than 10 WBC/cu.mm. in the suprapubic aspirate was not usually associated with a positive culture. Only 2 infants from a total of 70 studied in the special care unit had more than 100,000 organisms/ml. with more than 10 WBC/cu.mm. in the bladder urine. All urines, which were obtained from infants whose mothers had bacteriuria in the last trimester of pregnancy, were sterile. These results support the view that neonatal urinary infection is uncommon and that infants of this age is not justified.