Pyelonephritis in male infants: how important is the foreskin?

Meta-analysis of the Risk Factors for Urinary Tract Infection in Children

CONTEXT

The incidence of urinary tract infection (UTI) varies with age, but there is limited evidence on the role of other risk factors.

OBJECTIVE

The aim of this meta-analysis was to investigate the risk factors for UTIs in children.

DATA SOURCES

PubMed from 1966 to May 2019.

STUDY SELECTION

All studies assessing at least 1 possible risk factor for occurrence or recurrence of UTI with a clear definition of symptomatic UTI in children were eligible. We excluded studies with UTIs related to hospital treatment or severe congenital renal abnormalities.

DATA EXTRACTION

After the quality assessment we extracted data on the given risk factor in children with and without UTI. The data were extracted separately for the occurrence and recurrence of UTIs.

RESULTS

We included 24 studies in the meta-analysis. Circumcision decreased the occurrence of UTIs with an odds ratio (OR) of 0.1 [95% confidence interval (CI): 0.06-0.17) and breast-feeding with an OR of 0.4 (CI: 0.19-0.86), both with low heterogeneity. Being overweight or obese increased the risk of UTI (OR: 2.23; CI: 1.37-3.63). Both poor fluid intake (OR: 6.39; CI: 3.07-13.39) and infrequent voiding (OR: 3.54; CI: 1.68-7.46) were associated with recurrent UTIs.

LIMITATIONS

The design, populations and definitions varied between the studies.

CONCLUSIONS

Being overweight or obese and having poor fluid intake are modifiable risk factors that increase the risk for UTIs in children. Breast-feeding and circumcision are associated with a decreased occurrence of UTIs.

Asian guidelines for urinary tract infection in children

The followings are the level of evidence (LE) and grade of recommendation (GR) on pediatric UTI in Asia. Classification according to the sites of infection (lower versus upper tract), the number of episode (first versus recurrent), the severity (simple versus severe), or the existence of complicating factor (uncomplicated versus complicated) is useful to differentiate children with UTI whether they are at risk of renal damage or not (LE: 2, GR: B). Diagnosis of UTI requires both urinalysis that suggests infection and positive urine culture (LE:3, GR B). For pre-toilet trained children, urine specimen for culture should be collected by urethral catheterization or suprapubic aspiration. For toilet trained children, midstream clean catch urine is reliable (LE: 3, GR: A). Urine culture is considered positive if it demonstrates growth of a single bacterium with the following colony counts: (1) any growth by suprapubic aspiration, (2) >5 × 104 CFU/ml by urethral catheterization, or (3) >105 CFU/ml by midstream clean catch (LE:3, GR: B). For children with febrile UTI, renal and bladder ultrasonography (RBUS) should be routinely performed as soon as possible (LE: 3, GR: C). RBUS should be followed up 6 months later in children with acute pyelonephritis and/or VUR (LE: 3, GR: C). Acute DMSA scan can be performed when severe acute pyelonephritis or congenital hypodysplasia is noted on RBUS or when the diagnosis of UTI is in doubt by the clinical presentation (LE: 3, GR: C). Late DMSA scan (>6 months after the febrile UTI) can be performed in children with severe acute pyelonephritis, high-grade VUR, recurrent febrile UTIs, or abnormal renal parenchyma on the follow-up RBUS (LE: 3, GR: C). Top-down or bottom-up approach for febrile UTI is suggested for the diagnosis of VUR. For top-down approach, VCUG should not be performed routinely for children after the first febrile UTI. VCUG is indicated when abnormalities are apparent on either RBUS or DMSA scan or both (LE: 2, GR: B). VCUG is also suggested after a repeat febrile UTI (LE:2, GR: B). Appropriate antibiotic should be given immediately after urine specimen for culture has been obtained (LE:2, GR: A). Initiating therapy with oral or parenteral antibiotics is equally efficacious for children (>3 months) with uncomplicated UTI (LE: 2: GR: A). The choice of empirical antibiotic agents is guided by the expected pathogen and the local resistance patterns (LE: 2, GR: A). For children with febrile UTI, the total course of antibiotic therapy should be 7-14 days (LE: 2, GR: B). Circumcision may, but not definitively, reduce the risk of febrile UTI in males and breakthrough febrile UTI in males with VUR. Circumcision should be offered to uncircumcised boys with febrile UTI and VUR in countries where circumcision is accepted by the general population (LE: 3, GR: B), while in countries where childhood circumcision is rarely performed, other measures for febrile UTI/VUR should be the preferred choice (LE: 4, GR: C). Bladder bowel dysfunction (BBD) is one of the key factors of progression of renal scarring (LE: 2). Early recognition and management of BBD are important in prevention of UTI recurrence (LE:2, GR: A). Antibiotic prophylaxis to prevent recurrent febrile UTI is indicated in children with moderate to high grade (III-V) VUR (LE: 1b, GR: A). Surgical intervention may be used to treat VUR in the setting of recurrent febrile UTI because it has been shown to decrease the incidence of recurrent pyelonephritis (LE: 2, GR: B).

High incidence of abnormal imaging findings in circumcised boys diagnosed with urinary tract infections

BACKGROUND

The American Academy of Pediatrics guidelines recommend delaying voiding cystourethrogram (VCUG) until the second febrile urinary tract infection (UTI). Similarly, the NICE Guidelines do not recommend VCUG after the first febrile UTI in infants and children under three years of age. Currently, there is no good clinical indicator to determine which patients would benefit from an earlier cystogram. Here, we sought to identify clinical and bacteriologic findings that are associated with an increased risk of urinary tract anatomic anomalies in pediatric males presenting to the Emergency Department with a UTI.

METHODS

A retrospective review was performed of all urine cultures from the Emergency Department at our institution between 2006 and 2015. Males under 18 years of age with ≥50,000 CFU/mL of Proteus, Klebsiella, Escherichia coli, Staphylococcus, Streptococcus and Enterococcus were included. Clean catch, catheterized and suprapubic aspiration specimens were included. Bagged specimens and specimens from patients on intermittent catheterization were excluded. Ultrasound and cystogram images were reviewed when available. Univariate and multivariable Poisson regression with robust variance was used to calculate and compare prevalence ratios. Statistical analysis was performed with Stata software, version 15.1 MP (Stata Corporation, College Station, Texas, USA).

RESULTS

We reviewed 1585 urine cultures, of which 812 met eligibility criteria including 619 (76.2%) E. coli, 84 (10.3%) Proteus, 55 (6.8%) Klebsiella, 29 (3.6%) Staphylococcus, 13 (1.6%) Enterococcus and 12 (1.5%) Streptococcus. Median age was six months (2.4-36 months IQR). After adjusting for age, ethnicity and bacterial species, the prevalence of dilating vesicoureteral reflux (VUR, defined as grades III-V) was 5.3 times higher in circumcised males compared to uncircumcised males (95% CI: 2.4-11.4, p = 0.001). Circumcised males had a 3.1 times increased prevalence of high-grade hydronephrosis (defined as SFU grades 3 and 4) compared to uncircumcised males (prevalence ratio: 3.1, 95% CI: 1.0-10.0, p = 0.05). Among bacterial pathogens, no patients with Proteus UTI had high-grade hydronephrosis or dilating VUR. In contrast, Staphylococcal infections were associated significantly with dilating VUR (prevalence ratio 10.1, 95% CI: 2.3, 44.8; p = 0.002) and high-grade hydronephrosis (prevalence ratio 8.1, 95% CI: 1.7, 39.7; p = 0.010).

CONCLUSIONS

Circumcision status is an independent predictor of structural urinary anomalies of the bladder and upper tracts in pediatric males with UTI, therefore circumcised males should be considered for early imaging, including VCUG, after their first UTI. Furthermore, Staphylococcal infections were associated with an even higher prevalence of high-grade hydronephrosis and dilating VUR and therefore warrant early investigation with VCUG. In contrast, none of the Proteus infections, which were seen almost exclusively in uncircumcised males, were associated with dilating VUR or hydronephrosis, making initial observation more appropriate in these patients.

A Cost-Utility Analysis of Neonatal Circumcision

A cost-utility analysis, based on published data from multiple observational studies, comparing boys circumcised at birth and those not circumcised was undertaken using the Quality of Well-being Scale, a Markov analysis, the standard reference case, and a societal perspective. Neonatal circumcision increased incremental costs by $828.42 per patient and resulted in an incremental 15.30 well-years lost per 1000 males. If neonatal circumcision was cost-free, pain-free, and had no immediate complications, it was still more costly than not circumcising. Using sensitivity analysis, it was impossible to arrange a scenario that made neonatal circumcision cost-effective. Neonatal circumcision is not good health policy, and support for it as a medical procedure cannot be justified financially or medically.

Circumcision and lifetime risk of urinary tract infection: a systematic review and meta-analysis

PURPOSE

Urinary tract infection is common in infant males who are uncircumcised and can lead to renal parenchymal disease of the still growing pediatric kidney. Although the rate of urinary tract infection is highest in the first year of life, the cumulative incidence during the rest of the lifetime is under-recognized, but is expected to be nontrivial. Thus, any intervention that might prevent urinary tract infection would be expected to reduce suffering and medical costs.

MATERIALS AND METHODS

We conducted a meta-analysis of 22 studies examining the single risk factor of lack of circumcision, then determined the prevalence and relative risk of urinary tract infection in different age groups (0 to 1, 1 to 16 and older than 16 years). From these data we estimated the lifetime prevalence.

RESULTS

For age 0 to 1 year the relative risk was 9.91 (95% CI 7.49-13.1), for age 1 to 16 years RR was 6.56 (95% CI 3.26-13.2) and for older than 16 years it was 3.41-fold (95% CI 0.916-12.7) higher in uncircumcised males. We then calculated that 32.1% (95% CI 15.6-49.8) of uncircumcised males experience a urinary tract infection in their lifetime compared with 8.8% (95% CI 4.15-13.2) of circumcised males (RR 3.65, 95% CI 1.15-11.8). The number needed to treat was 4.29 (95% CI 2.20-27.2).

CONCLUSIONS

The single risk factor of lack of circumcision confers a 23.3% chance of urinary tract infection during the lifetime. This greatly exceeds the prevalence of circumcision complications (1.5%), which are mostly minor. The potential seriousness of urinary tract infection supports circumcision as a desirable preventive health intervention in infant males.

Complications of circumcision

In the United States, circumcision is a commonly performed procedure. It is a relatively safe procedure with a low overall complication rate. Most complications are minor and can be managed easily. Though uncommon, complications of circumcision do represent a significant percentage of cases seen by pediatric urologists. Often they require surgical correction that results in a significant cost to the health care system. Severe complications are quite rare, but death has been reported as a result in some cases. A thorough and complete preoperative evaluation, focusing on bleeding history and birth history, is imperative. Proper selection of patients based on age and anatomic considerations as well as proper sterile surgical technique are critical to prevent future circumcision-related adverse events.

Treatment Role of Circumcision in Urinary Tract Infections in Children Less than Five Years of Age in Mosul City 2010

To investigate the possible role of circumcision in decreasing urinary tract infections in children less than five years of age the clinical and laboratory findings of 100 cases of urinary tract infection admitted to Al Khansaa Pediatrics Hospital were compared with a similar number of apparently healthy children. The results showed a strong relationship between circumcision and decreased incidence of urinary tract infections and that the risk of urinary tract infections in uncircumcised children was more than six-fold that of circumcised children of the same age.

RACP's policy statement on infant male circumcision is ill-conceived

OBJECTIVE

To conduct a critical peer-review of the 2004 Policy Statement on routine male circumcision produced by the Royal Australasian College of Physicians (RACP).

METHOD

Comprehensive evaluation in the context of the research field.

RESULTS

We find that the current Statement downplays the wide-ranging life-long benefits of circumcision in prevention of urinary tract infections (UTIs), penile and cervical cancer, genital herpes and chlamydia in women, HIV infection, phimosis, and various penile dermatoses, and at the same time overstates the complication rate. We highlight the many errors in the RACP Statement and note that it sidesteps making a conclusion based on circumcision's well-documented prophylactic health benefits by instead referring to the status of the foreskin at birth. In the era of preventative medicine we view this as irresponsible.

CONCLUSION

The RACP's Statement on routine male circumcision is not evidence-based and should be retracted.

IMPLICATIONS

In the interests of public health and individual well-being an extensive, comprehensive, evidence-based revision should be conducted so as to provide scientifically accurate, balanced information on the advantages, and also the low rate of mostly minor complications, associated with this simple procedure, which for maximum benefits and minimal risk should ideally be performed in the neonatal period.

Controversies in the diagnosis and management of urinary tract infections in children

Urinary tract infection (UTI) is one of the most common childhood bacterial infections, after upper respiratory tract and middle ear infections. The current goal of management is to prevent detrimental effects of UTI by early detection and treatment. Recommendations for the imaging of children depend upon age at presentation and sex. All children aged <5 years who have had a febrile UTI require a radiologic evaluation to identify any underlying genitourinary pathology. Older children can undergo a more tailored work-up depending on whether there is a febrile UTI or cystitis-type symptoms. Dysfunctional voiding and urge syndrome significantly increase the risk of developing UTIs in children. Vesicoureteral reflux can increase the risk of pyelonephritis and renal scarring in children with UTIs. For the most part, pyelonephritis can be diagnosed on clinical grounds in the majority of patients and a subsequent (99m)Tc-dimercaptosuccinic acid scan can be reserved to identify post-nephritic renal scarring. When renal scarring is identified, the child and parents need to be educated regarding the possibility of hypertension, proteinuria, progressive nephropathy, and the risk of complications in future pregnancies. Treatment of UTI is started in the unwell child before the culture results are available and subsequently changed to culture-specific antimicrobial therapy. A short course of treatment is required for acute uncomplicated UTIs. A child with acute pyelonephritis requires 10-14 days of antibacterial treatment. The oral route in young children often causes vomiting, which implies therapeutic delay, a well known risk factor for scarring.

Circumcision for the prevention of urinary tract infection in boys: a systematic review of randomised trials and observational studies

OBJECTIVE

To undertake a meta-analysis of published data on the effect of circumcision on the risk of urinary tract infection (UTI) in boys.

DATA SOURCES

Randomised controlled trials and observational studies comparing the frequency of UTI in circumcised and uncircumcised boys were identified from the Cochrane controlled trials register, MEDLINE, EMBASE, reference lists of retrieved articles, and contact with known investigators.

METHODS

Two of the authors independently assessed study quality using the guidelines provided by the MOOSE statement for quality of observational studies. A random effects model was used to estimate a summary odds ratio (OR) with 95% confidence intervals (CI).

RESULTS

Data on 402,908 children were identified from 12 studies (one randomised controlled trial, four cohort studies, and seven case-control studies). Circumcision was associated with a significantly reduced risk of UTI (OR = 0.13; 95% CI, 0.08 to 0.20; p<0.001) with the same odds ratio (0.13) for all three types of study design.

CONCLUSIONS

Circumcision reduces the risk of UTI. Given a risk in normal boys of about 1%, the number-needed-to-treat to prevent one UTI is 111. In boys with recurrent UTI or high grade vesicoureteric reflux, the risk of UTI recurrence is 10% and 30% and the numbers-needed-to-treat are 11 and 4, respectively. Haemorrhage and infection are the commonest complications of circumcision, occurring at rate of about 2%. Assuming equal utility of benefits and harms, net clinical benefit is likely only in boys at high risk of UTI.

Effect of circumcision on urinary tract infection after successful antireflux surgery

OBJECTIVE

To evaluate whether circumcision during antireflux surgery can reduce the incidence of urinary tract infection (UTI) after successful ureteric reimplantation in patients with primary vesico-ureteric reflux (VUR).

PATIENTS AND METHODS

Children who had undergone antireflux surgery for primary VUR were divided into group 1 (27, circumcised at the time of antireflux surgery at the parents' request) and group 2 (50, those not circumcised). All antireflux operations were by the Cohen method. Regular urine samples were cultured to detect UTI, which was defined as a single species with >10(5) colony-forming units/mL in a midstream voided specimen. Numbers of UTI episodes before and after surgery were compared between the groups, with (99m)Tc-dimercaptosuccinic acid (DMSA) renal scans also taken in all patients. Each scan was blindly reviewed in terms of the size, number and zonal location of cortical defects, based on morphology. Interval changes were categorised as improved, no change, progressed, and new scar formation, and compared between the groups. Prophylactic antibiotics were maintained until the follow-up studies at 4-6 months after surgery.

RESULTS

There was no significant difference between the groups in age at the time of operation (mean 42.4 vs 47.4 months), the age at the first documented UTI (mean 26.5 vs 29.3 months), reflux grade, or number of UTI episodes and renal parenchymal scarring on DMSA before surgery. There was no significant difference between the groups in the number of UTI episodes at a mean (range) follow-up of 151.3 (114-207) months after antireflux surgery. Also there was no significant morphological change on follow-up renal scans and no difference between the groups.

CONCLUSION

These findings suggest that circumcision during antireflux surgery has no effect on the incidence of postoperative UTI.

Male neonatal circumcision: indications, controversies and complications

The debate about whether to circumcise infants in the neonatal period likely will continue. As the medical and ethical issues are discussed and studied, however, economic factors are beginning to limit the practice in the United States. As the shift in reimbursement occurs, parents who believe that circumcision is a medically necessary practice will need to be reassured that their child may lead a healthy life with an intact foreskin.

Infant vesicoureteral reflux: a comparison between patients presenting with a prenatal diagnosis and those presenting with a urinary tract infection

OBJECTIVES

To evaluate the severity, laterality, and gender distribution of infant vesicoureteral reflux (VUR) and its potential impact on renal outcome, we compared patients presenting fetally (FDR group) and those presenting with a urinary tract infection (INF group).

METHODS

A retrospective review of 202 patients with the diagnosis of VUR before 6 months of age was performed. The grade of VUR, gender, laterality, initial renal scarring, breakthrough urinary tract infections, new renal scarring, and surgical intervention were compared between the INF group (n = 146) and FDR group (n = 56).

RESULTS

The male/female ratio in the FDR group was 1.67:1 compared with 0.60:1 in the INF group. The FDR group had more unilateral VUR than the INF group (P <0.001), and no significant difference was found between the two groups in terms of VUR grade distribution (P = 0.13), percentage of initial damage (28% of FDR patients versus 23% of INF patients), or clinical course. In either group, boys and girls exhibited a very similar distribution of grade and renal damage.

CONCLUSIONS

Our findings do not support the commonly held belief that fetally diagnosed reflux is an overwhelmingly male, bilateral, and high-grade phenomenon. Few differences were observed between infants diagnosed fetally and those diagnosed subsequent to urinary tract infection. Once diagnosed, from either group, infant reflux has neither great morbidity nor a frequent need for surgery.

Circumcision: a consideration of some of the controversy

This article considers the procedure known as male circumcision. This is practised throughout the world for a variety of reasons, including medically essential reasons, health promotion, health protection, cultural, religious and aesthetic. It has been estimated that approximately one-third of the male population has been circumcized. As with some other surgical interventions its use is controversial, and there are a number of ethical and moral issues that are of interest to the children's nurse. The anatomy and physiology of the prepuce is summarized and the practice of circumcision and some of the risks and proposed benefits of the procedure are considered. This article is intended to be culturally sensitive and it is hoped that it will inform others and provoke discussion. It may enable the children's nurse to raise awareness of the issues among the general population.

Meatus tightly covered by the prepuce is associated with urinary infection

BACKGROUND

Almost all newborns have phimosis, which is known as one of the risk factors for urinary infection. The present study analyzed which specific prepuce conditions correlated with the development of febrile urinary infection in Japanese male infants.

METHODS

The subjects consisted of 100 children, 64 boys and 36 girls, with febrile urinary infection. Prepuces were classified by their retractability in the male patients and in 714 healthy boys.

RESULTS

Ninety-four percent of first febrile urinary infections occurred before 7 months of age in boys, whereas only 37% of the girls had first infections by that age. The prepuce covered the external urethral meatus in 96% of the healthy boys aged 3 years or less. A gentle retraction maneuver could not uncover the urethral meatus in approximately 40% of the boys aged 0-6 months. The frequency started to decline spontaneously after that age. Male patients aged 0-6 months significantly more often had tightly covered meatus than did healthy neonates (85%vs 42%, P < 0.0001).

CONCLUSIONS

These findings indicate that it is specifically those boys whose external urethral meatus are tightly covered with foreskin who constitute the high-risk group for urinary infection. Awareness of this observation should help with diagnosing and managing urinary infection in young boys.

Bacterial colonization of the prepuce in boys with vesicoureteral reflux who receive antibiotic prophylaxis

Culture swabs were taken from the periurethral area of 59 consecutive uncircumcised boys with vesicoureteral reflux (VUR) and 36 boys undergoing circumcision. A pure growth of a uropathogen was isolated in 22 (37%) boys with VUR who were receiving antibiotic prophylaxis and in 10 (28%) boys who underwent circumcision. Antibiotic prophylaxis in patients with VUR was not effective in reducing the bacterial colonization of the prepuce. We recommend circumcision in boys, particularly infants with VUR, to reduce the risk of urinary tract infections.

Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life

OBJECTIVE

To assess the effect of newborn circumcision on the incidence and medical costs of urinary tract infection (UTI) during the first year of life for patients in a large health maintenance organization.

SETTING

Kaiser Permanente Medical Care Program of Northern California (KPNC).

PATIENTS

The population consisted of members of KPNC. The study group consisted of a cohort of 28 812 infants delivered during 1996 at KPNC hospitals; of the 14 893 male infants in the group, 9668 (64.9%) were circumcised. A second cohort of 20 587 infants born in 1997 and monitored for 12 months was analyzed to determine incidence rates.

DESIGN

Retrospective study of all infants consecutively delivered at 12 facilities.

OUTCOME MEASURES

Diagnosis of UTI was determined from the KPNC computerized database using the International Classification of Diseases, Ninth Revision code for inpatients and KPNC Outpatient Summary Clinical Record codes for outpatients. A sample of 52 patient charts was reviewed to confirm the International Classification of Diseases, Ninth Revision and KPNC Outpatient Summary Clinical Record codes and provide additional data.

RESULTS

Infants <1 year old who were born in 1996 had 446 UTIs (292 in females; 154 in males); 132 (86%) of the UTIs in males occurred in uncircumcised boys. The mean total cost of managing UTI was 2 times as high in males ($1111) as in females ($542). This higher total cost reflected the higher rate of hospital admission in uncircumcised males with UTIs (27.3%) compared with females (7.5%); mean age at hospitalization for UTI was 2.5 months old for uncircumcised boys and 6.5 months old for girls. In 1996, total cost of managing UTI in uncircumcised males ($155 628) was 10 times higher than for circumcised males ($15 466) despite the fact that uncircumcised males made up only 35.1% of the male patient base in 1996, reflecting the more frequent occurrence of UTI in uncircumcised males (132 episodes) than in circumcised males (22 episodes), and the larger number of hospital admissions in uncircumcised males (38) than in circumcised males (4). The incidence of UTI in the first year of life was 1:47 (2.15%) in uncircumcised males, 1:455 (.22%) in circumcised males, and 1:49 (2. 05%) in females. The odds ratio of UTI in uncircumcised:circumcised males was 9.1:1.

CONCLUSIONS

Newborn circumcision results in a 9. 1-fold decrease in incidence of UTI during the first year of life as well as markedly lower UTI-related medical costs and rate of hospital admissions. Newborn circumcision during the first year of life is, thus, a valuable preventive health measure, particularly in the first 3 months of life, when uncircumcised males are most likely to be hospitalized with severe UTI.

Evaluation and management of pediatric urinary tract infections

Urinary tract infections (UTIs) are relatively common in children. We describe the evaluation and management of children with UTIs, as well as the risks and consequences related to the UTI. This article describes a rational approach to the evaluation and management of childhood UTIs with the relation to the natural history and risk factors.

Circumcision policy statement. American Academy of Pediatrics. Task Force on Circumcision

Existing scientific evidence demonstrates potential medical benefits of newborn male circumcision; however, these data are not sufficient to recommend routine neonatal circumcision. In circumstances in which there are potential benefits and risks, yet the procedure is not essential to the child's current well-being, parents should determine what is in the best interest of the child. To make an informed choice, parents of all male infants should be given accurate and unbiased information and be provided the opportunity to discuss this decision. If a decision for circumcision is made, procedural analgesia should be provided.

Urinary tract infections in children. Epidemiology, evaluation, and management

Accurate documentation of UTIs in children is essential for proper evaluation and management. Urine cultures with multiple organisms or colony counts less than 50,000 to 100,000 CFU/ml should be considered suspect and require confirmation, particularly with clean-catch specimens. Children with well-documented UTIs should be evaluated based on their age and presenting symptoms. Infants and young children require imaging, usually with a cystogram and sonogram of the kidneys and bladder. Older girls with febrile UTIs and boys at any age should also be considered for urinary tract imaging. Renal cortical scintigraphy with 99mTc-DMSA has emerged as the imaging study of choice for acute pyelonephritis and renal scarring in children with UTIs. Treatment of UTIs in children ideally commences with culture-specific antimicrobial therapy, although treatment may be started in sick children before culture results are available. Short-course treatment (3-5 days) is sufficient for children with acute uncomplicated lower UTIs. Children with acute pyelonephritis require 10 to 14 days of antibiotics, which can be administered on an outpatient basis in older infants and children who are not toxic, as long as good compliance is expected. Patients with first-time UTIs who require imaging should be maintained on low-dose antibiotic prophylaxis until their workup is completed. Treatment of ABU does not seem necessary if the urinary tract is otherwise normal. Long-term antibiotic prophylaxis is indicated for children with frequent symptomatic recurrences of UTI and for those with known VUR. Diagnosis and treatment of underlying voiding dysfunction and constipation is an essential component of the successful management of UTIs in children.

Congenitally small kidneys with reflux as a common cause of nephropathy in boys

Congenital maldevelopment is sometimes found in small kidneys with ureteral reflux. However, the incidence of congenitally small kidneys and the frequency of its association with ureteral reflux remains unknown. Ultrasound scanning, performed in 4,000 apparently healthy neonates or young infants (males 2,129, females 1,871), detected 51 children suspected of having small kidneys. A careful ultrasound re-examination performed one month later in 45 of the 51 children confirmed small kidneys in eight children, one bilateral and seven unilateral. Dimercaptosuccinate (DMSA) renoscintigraphy revealed small kidneys with generally diminished uptake in six infants and no uptake unilaterally in the other two infants. One of the 12 children, who had normal findings on the initial scanning and subsequently developed urinary infection, was later diagnosed having unilateral small kidney with generally reduced DMSA uptake. All seven infants having small kidneys with reduced tracer uptake were male (incidence, 1:300 boys). All eight small kidneys in the seven boys and four of the six contralateral non-small kidneys were associated with ureteral reflux, while neither of the two infants with a non-functioning kidney had ureteral reflux. Serial ultrasounds documented the poor growth of all small kidneys. Thus, congenitally small kidneys with generally diminished DMSA uptake were highly associated with ureteral reflux and especially observed in boys.

Ultrasonography for the detection of ureteric reflux in infants with urinary infection

Several less harmful methods than voiding cysto-urethrography for detecting significant ureteric reflux have been proposed. The present prospective study investigated whether ultrasonography was effective in identifying ureteric reflux in infants with their first febrile urinary infection. The subjects were 27 infants (24 boys and 3 girls) aged from 0 to 8 months. The urinary tract was scanned when the bladder was full, and before and during induced voiding. Infants with abnormal ultrasound findings underwent voiding cysto-urethrography. The other infants were followed and those who had a recurrence of urinary infection underwent voiding cystography. Ten children underwent cysto-urethrography, with eight refluxing ureters identified in six boys. Ultrasound revealed transient dilatation of the renal pelvis on voiding in five kidneys, transient dilatation of distal ureters in 12 and hydro-ureteronephrosis in two. Each of the five kidneys with pelvic dilatation on voiding was associated with ureteric reflux grades III or IV. Of the 17 children who did not undergo cysto-urethrography, only one had recurrence of urinary infection and was diagnosed with ureteric reflux. This girl was one of the three babies who were not scanned during voiding. More than half of the infants with febrile urinary infection were excluded from invasive examination without having recurrence of urinary infection. Thus, ultrasound scanning during voiding was effective for screening infants with their first urinary infection to detect significant ureteric reflux.

Urinary tract infections and the uncircumcised state: an update

In a two-part study of the circumcision status of boys with urinary tract infections (UTIs), we reviewed the occurrence of UTIs in 209,399 infants born in US Army hospitals worldwide from 1985 to 1990. During the first year of life, 1,046 (0.5%: 550 girls and 496 boys) were hospitalized for UTIs. Noncircumcised male infants had a 10-fold greater incidence of infection than did circumcised male infants. The frequency rate of circumcision rose significantly, from 70.3% to 80.2%, during the study period. Among uncircumcised boys younger than 3 months with UTIs, 23% had concomitant bacteremia involving the same organism. The second part of the study consisted of a meta-analysis of all nine previous reports on the circumcision status of boys with UTIs. These studies revealed a fivefold to 89-fold increased risk of infection in uncircumcised boys; the combined data yielded a 12-fold increase in UTIs in this population. Parents should be told of the lower risk of UTIs for circumcised boys during informed-consent counseling.

Circumcision--an update

Circumcision will likely continue to be a frequently performed procedure during the neonatal period. Rather than allowing it to be an emotion-laden issue, clinicians should keep abreast of ongoing developments in the field and be able to present thorough, objective counseling. Informed parental refusal requires no less.