Urologic viewpoints on the treatment of urinary tract infections in children

Screening of newborn babies for familial ureteric reflux

BACKGROUND

Vesicoureteric reflux (VUR) is not usually diagnosed until it is complicated by urinary infection. Prevention probably requires diagnosis in a newborn baby before urinary infection occurs because the peak incidence for infection is in early infancy. VUR is a familial disorder. We sought to find out whether an at-risk group of newborn babies could be identified on the basis of the parents' family history.

METHODS

Over a 3-year period, pregnant women attending the antenatal clinics of three hospitals in the northeast of England were screened for evidence of urinary-tract disease in themselves or their families with a view to eliciting a history of VUR. When a woman, her partner, or a member of either family had a definite (by cystography records) or probable positive history, we recruited the mother to our study. Renal ultrasonography and cystography were done on the newborn babies soon after delivery, and a dimercaptosuccinic acid (DMSA) radioisotope scan at 3 months was done on those with VUR.

FINDINGS

The estimated number of deliveries during the study period was 34,555; 20,891 women were screened; and 211 were recruited and delivered. The index cases were identified from a wide range of family relationships, though over half consisted of mothers and siblings, 19 babies had more than one index case and in 21 families there was one index for more than one baby or a link between families. Cystography was carried out on 186 newborn babies; 38 (20.4%) had VUR. The proportion of newborn babies with VUR among linked index families was 31%. Mothers and siblings amounted to 71% of the index cases for newborn babies with VUR. The difference between confirmed and assumed index cases in VUR prediction was not significant. The female/male sex ratio among index cases was more than 4, but among newborn babies with VUR it was 1.5. Renal ultrasound showed no correlation with VUR, and all DMSA scans but one were normal. No newborn baby developed complications resulting from cystography.

INTERPRETATION

The screening of pregnant women for familial VUR is worthwhile because the frequency of VUR among the newborn babies of those with such a history is significantly higher than in the general population (frequency of VUR 1-2%), particularly if the family history involves more than one member, or more than one generation.

Active surgical management of primary vesicoureteral reflux in adults

Of 27 adults with primary vesicoureteral reflux, 23 were treated surgically. These patients had suffered from chronic urinary-tract infections with poor response to conservative therapy. Urography revealed inflammatory changes in one or both kidneys in 18 patients, as well as other renal or ureteral deformities. Micturition cystography showed reflux reaching the renal pelvis and dilatation of the pelvis and ureter in 18 patients (28 ureters). An antireflux operation was performed on 32 ureters and in all cases was followed by disappearance of the reflux. No ureteral stricture developed postoperatively. During an observation period averaging more than three years only three patients had postoperative urinary-tract infections. These occurred when a short period of medication was terminated. On the basis of present experience we consider that antireflux surgery is indicated for all adults with vesicoureteral reflux and urinary-tract infections or progressive dilatation of the upper urinary tract.