Patient Characteristics Associated with Sexual Interest and Activity Among Adults with Spina Bifida

OBJECTIVE

To identify factors associated with sexual interest and activity among adults with spina bifida and to describe the sexual profile of those who were sexually active. Sexual health of adults with spina bifida is often neglected and current knowledge on the topic is limited.

METHODS

An anonymous web-based survey was advertised and administered between March 2018 and September 2018 and participants 16 years and older with spina bifida were included in this study. Respondents were asked about sexual interest, activity, and function using the validated Patient-Reported Outcomes Measurement Information System Sexual Function Profile. Bivariate and multivariable models with ordinal logistic regression were fitted to evaluate predictors of sexual interest and sexual function.

RESULTS

Of the 261 respondents with a self-reported diagnosis of spina bifida (mean age of 38.5 years), 73.2% noted at least a little bit of interest in sexual activity. In multivariate analysis, women were less likely to report higher sexual interest than men (odds ratio (OR) = 0.53, 95% CI 0.31-0.92, P = .03) whereas those with higher physical functioning were more likely to have higher sexual interest (OR = 1.04, confidence interval (CI) 1.01-1.07, P = .03). Just less than half of respondents (46.4%) were sexually active in the past 30 days, and those with a ventriculoperitoneal shunt were less likely to engage in sexual activity compared to those without (OR = 0.36, 95% CI 0.19-0.68; P <.01).

CONCLUSION

The mismatch between sexual interest and sexual activity highlights the importance of exploring issues related to sexual health when counseling adult patients with spina bifida.

Urinary tract infections in pediatric orthopedic surgical patients: a Single Institution National Surgical Quality Improvement Program Study

OBJECTIVE

Perioperative urinary tract infections (UTIs) are poorly studied among pediatric orthopedic surgical patients. We evaluated the incidence of and risk factors for UTI in a large volume of pediatric orthopedic surgical patients.

METHODS

Children <18 who underwent orthopedic surgery between March 2015 and December 2018 were analyzed using our institution's National Surgical Quality Improvement Program (NSQIP) data. Demographic, perioperative and outcome data of patients who developed a UTI within 30 days of surgery were compared to patients without UTI.

RESULTS

NSQIP data were available for 520 surgeries (324 girls and 196 boys). Median age at surgery was 13.5 years. A Foley was placed in 301/520 cases (88/196 boys and 213/324 girls) in 264 children. Six cases of UTI occurred within 30 days of surgery (1.2% of surgeries). The UTI rate among patients with a Foley was 2.3%, and among girls with a Foley was 2.8%. No UTIs occurred without a Foley, nor any in boys. All six occurred in the American Society of Anesthesiologists Class 2 females, ages 7-15 undergoing elective surgery with Foley for over 48 h. Factors associated with an increased odds of developing UTI included: higher BMI [OR, 1.12 (CI, 1.01-1.22; P = 0.03)], developmental delay [OR, 7.82 (CI, 1.40-43.7; P = 0.02)], structural central nervous system abnormality [OR, 17.5 (CI, 3.89-90.4; P = 0.01)], longer duration with Foley [OR, 1.68 (CI, 1.22-2.32; P = 0.002)] and hospital readmission within 30 days [OR 14.2 (CI, 2.32-87.3; P = 0.004)].

CONCLUSION

Risk of UTI is low after pediatric orthopedic surgery. Girls with comorbidities including structural central nervous system abnormality, developmental delay and higher BMI with prolonged Foley catheterization may have higher postoperative UTI risk. Level of Evidence: II.

Revisiting the utility of prenatal ultrasound in the routine workup of first febrile UTI: A systematic review and meta-analysis of the negative predictive value of prenatal ultrasound for identification of urinary tract abnormalities after first febrile urinary tract infection in children

CONTEXT

The current EAU/ESPU and recently retired AAP pediatric UTI guidelines recommend renal bladder ultrasound after first febrile UTI in children to screen for structural abnormalities, regardless of findings on prenatal ultrasound.

OBJECTIVE

Test the hypothesis that a normal prenatal ultrasound could rule out urinary tract abnormality on post-UTI ultrasound.

DATA SOURCES

Medline, Embase, Cochrane Library.

STUDY SELECTION

Studies including pediatric patients with first febrile UTI who had both prenatal and post-UTI ultrasound.

DATA EXTRACTION

Anatomical abnormalities detected by prenatal and post-UTI ultrasound as reported per individual study criteria were extracted. Meta-analyses of 9 studies (2981 patients) were performed using a random-effects model and composite estimates of the negative predictive value (NPV) of prenatal ultrasound were calculated.

RESULTS

Overall summary NPV of prenatal ultrasound for all pediatric patients was 77%, with heterogeneity score (I2) 97.9%. Summary NPV of prenatal ultrasound for all patients under two years of age was similar at 75%, with I2 98.2% For the 4 studies to which we could apply a more stringent definition of abnormality, summary NPV was 85% and I2 97.5% for prediction of moderate post-UTI ultrasound abnormalities and summary NPV was 93% and I2 90.4% for severe abnormalities.

DISCUSSION

While we calculated an 85% NPV for a normal prenatal ultrasound to rule out significant postnatal abnormality as defined within individual studies, substantial heterogeneity amongst publications limited the precision of our estimates. This highlights the need for more rigorous investigations with attention to timing of ultrasound and the application of clinically meaningful definitions for abnormal prenatal and post-UTI studies. This may allow judicious use of prenatal ultrasound to guide clinical management for children with first febrile UTI and minimize redundant imaging with potential for false positive results. Until then, the current guidelines are justified based on the limited and heterogenous data from the currently available published studies.

Access and Utilization of Health Care by Adults with Spina Bifida

OBJECTIVE

To contextualize the challenges that persons with congenital genitourinary conditions (CGC) may encounter in adulthood, we examined health care access, readiness for self-management, and health care utilization of adults with spina bifida (SB).

METHODS

Through surveys distributed via social media, persons with SB were asked about access and barriers to care, readiness for self-management, and health care utilization (ie, medical visits, missed visits, emergency room [ER] visits, hospital admissions) within the past year. Multivariable models were fitted to examine determinants of utilization.

RESULTS

Of the 270 eligible respondents (mean age 39), 24.5% had not received care from a urologist in the past year. The odds of missing any medical visits were increased among those with more prior urologic surgeries (odds ratio (OR) 1.35, 95%confidence interval (CI) 1.05-1.78) and those with ER visits for urologic condition within the past year (OR 2.65, 95%CI 1.22-6.01). Those with private insurance had lower odds of having ER visits for urologic condition (OR 0.46, 95%CI 0.22-0.84). The odds of hospital admission related to urologic condition were increased among female (OR 2.35, 95%CI 1.01-6.64), those with more prior urologic surgeries (OR 1.18, 95%CI 1.09-1.51), and those with a urologist (OR 2.98, 95%CI 1.15-14.47).

CONCLUSION

A substantial proportion of adults with CGC lack routine urologic care. Considering the significant barriers to care and lapses in care, efforts to improve access and optimize health care services utilization for this population with high medical complexity are warranted.

Repurposing an ACE Malone Channel for Continent Intermittent Catheterization During Re-augmentation Cecocystoplasty: The MACEtrofanoff Procedure

OBJECTIVE

To describe a surgical alternative option in select patients with neurogenic bladder and a history of Malone antegrade continence enema (MACE) who now require revision augmentation of the bladder, and/or creation of a new continent catherizable urinary channel (CCC).

METHODS

Herein, we describe a novel surgical approach for patients who have had prior MACE creation who subsequently require surgical revision and creation of a new CCC. Rather than the traditional approach of creating a new CCC utilizing bowel, we perform a cecocystoplasty and leave the previously created MACE intact. The prior MACE channel becomes repurposed as the new Mitrofanoff, which we have termed the MACEtrofanoff channel. Concomitant cecostomy tube placement for bowel management can be performed at the time of surgery.

RESULTS

We have successfully performed this procedure in 2 patients with good outcomes to date. This technique does not require the sacrifice of the prior appendix channel, nor require the formation of a new stoma and channel. Patients are able to adapt easily to clean intermittent catheterization through a channel they are already familiar with for their prior antegrade enemas.

CONCLUSION

In select patients, surgeons should consider the MACEtrofanoff procedure to avoid the added morbidity of further bowel mobilization.

Health care utilization in young adults with childhood physical disabilities: a nationally representative prospective cohort study

BACKGROUND

Young people with physical disabilities face barriers to accessing health care; however, few studies have followed adolescents with physical disabilities longitudinally through the transition of care into adulthood. The objective of this study was to investigate differences in health care utilization between adolescents with physical disabilities and those without during the transition period from adolescent to adult care.

METHODS

We utilized the National Longitudinal Study of Adolescent to Adult Health, a prospective cohort study following adolescents ages 11-18 at baseline (1994-1995) through adulthood. Baseline physical disability status was defined as difficulty using limbs, using assistive devices or braces, or having an artificial limb; controls met none of these criteria. Health care utilization outcomes were measured seven years after baseline (ages 18-26). These included yearly physical check-ups, unmet health care needs, and utilization of last-resort medical care, such as emergency departments, inpatient hospital wards, and inpatient mental health facilities. Multiple logistic regression models were used to predict health care utilization, controlling for age, sex, race/ethnicity, insurance status, and history of depression.

RESULTS

Thirteen thousand four hundred thirty-six participants met inclusion criteria, including 4.2% with a physical disability and 95.8% without. Half (50%) of the sample were women, and the average age at baseline was 15.9 years (SE = 0.12). In logistic regression models, those with a disability had higher odds of unmet health care needs in the past year (Odds Ratio (OR) 1.41 95% CI 1.07-1.87), two or more emergency department visits in the past five years (OR 1.34 95% CI 1.06-1.70), and any hospitalizations in the past five years (OR 1.36 95% CI 1.07-1.72). No statistically significant differences in preventive yearly check-ups or admission to mental health facilities were noted.

CONCLUSIONS

Young adults with physical disabilities are at higher risk of having unmet health care needs and using last-resort health care services compared to their non-disabled peers.

A Child's urine is not sterile: A pilot study evaluating the Pediatric Urinary Microbiome

INTRODUCTION

A bladder microbiome (urobiome) exists in adults. Data supports the effects of the adult urobiome on urinary tract health with associations between dysbiotic urobiomes and lower urinary tract disorders. Understanding urobiome origin is important since other microbiomes establish around birth and microbiome alterations are linked to disease development. However, the pediatric urobiome has not been well studied.

OBJECTIVES

We sought to determine the age when the urobiome develops, compare the pediatric urobiome to microbiomes of adjacent urogenital niches, and compare the urobiomes between boys and girls and across age groups.

STUDY DESIGN

Seventy-four children less than 18 years of age without recent antibiotic exposure were recruited, including 48 males and 26 females, aged 2 weeks to 209 months of age. Transurethral catheterized urine samples and samples from the perineum, urethra, vagina, and foreskin were collected. Specimens were assessed using the expanded quantitative urine culture protocol and by 16S rRNA gene sequencing. Dada2 was used to profile microbial compositions, and BLCA was used to identify microbial taxa.

RESULTS

Bacteria were detected in 90.5% of urine samples and identified in children as young as 2 weeks of age. Microbial communities and compositions of the female bladder and other urogenital niches (urethra, perineum, and vagina) differed significantly by age. Lactobacillus predominated the bladder, urethral, and vaginal microbiomes in post-pubertal girls. Compared to female urinary microbiomes, those of males differed less substantially. Only perineal microbiomes differed significantly by age, whereas male urethral and foreskin microbiomes did not differ significantly.

DISCUSSION

We identified that a urinary microbiome is established as early as infancy. In addition, the female urobiome changes throughout childhood, until the post-pubertal bacterial taxa becomes consistent with that seen in adult females. Whereas in boys, the urinary microbiome changed very little over time. In addition, the surrounding urogenital microbiomes differed less in boys as compared to females. Microbiomes established at a young age may have long-term influences on immune, metabolic, and neurobehavioral traits. The same may be true for the urobiome. Our study provides a foundation for future research to determine the influence of the pediatric urobiome on the development of urinary and even non-urinary disorders.

CONCLUSIONS

A pediatric urobiome exists, with differences between males and females and can be detected at a young age with changes occurring throughout childhood. Similarities and differences are also seen between the pediatric urobiome and adjacent niches.

Practitioner counseling associated with improved opioid disposal among families of postoperative pediatric patients

BACKGROUND

Death from opioid-related overdose has doubled in recent years. Interestingly, there has been a similar increase in the number of opioid prescriptions. Medical providers, unfortunately, have contributed towards this rise in prescriptions. To combat the opioid epidemic, numerous efforts have been made to focus on the medical field and its role in the opioid epidemic. Proposed solutions for reduction of circulating opioids have included such measures as education, monitoring programs, alternative pain management strategies, and improved opioid disposal.

OBJECTIVES

We aimed to assess if counseling is associated with proper opioid disposal among families of post-operative pediatric patients.

STUDY DESIGN

We conducted a cross-sectional, convenience sample study of families of post-surgical, pediatric patients at a single academic institution. Participants completed a survey during their postoperative visit assessing opioid requirements, storage and disposal during and after the postoperative period, and if they were counseled by any medical professional on proper disposal methods. We used multivariable logistic regression to evaluate the association between the independent variables and the primary outcome.

RESULTS

We enrolled 180 participants, mean age of 8 years. Thirty-four percent reported having no opioid medication remaining at follow up because the medication was either consumed or the prescription was not filled. Sixty-six percent had leftover medication at the time of follow up. Sixty-six percent of participants knew the proper opioid disposal methods. However, only 22% of patients with leftover medication properly disposed of the medication. Patients who were counseled about proper opioid disposal were 3 times more likely to practice proper disposal practices than those who were not (p < 0.01).

DISCUSSION

Our study uniquely look at opioid consumption, disposal rates, and the effect of counseling in a diverse post-surgical pediatric population. Our findings confirm similar observations in the literature with regards to low opioid consumption, but in a larger, more surgically diverse cohort with a 100% response rate. Limitations included a lack of demographic diversity and lack of data measuring the impact of timing or frequency of counseling on opioid disposal practices. Further research goals would be to evaluate the effectiveness of counseling on proper opioid disposal, and the influence of timing and various counseling methods.

CONCLUSIONS

Most patients do not use all of their opioid medication prescription. Proper opioid disposal counseling by a medical professional may play an important role in adherence to recommended opioid disposal practices.

A multicenter study of acute testicular torsion in the time of COVID-19

BACKGROUND

Testicular torsion is a surgical emergency, and time to detorsion is imperative for testicular salvage. During the COVID-19 pandemic, patients may delay emergency care due to stay-at-home orders and concern of COVID-19 exposure.

OBJECTIVE

To assess whether emergency presentation for testicular torsion was delayed during the COVID-19 pandemic, and whether the rate of orchiectomy increased compared to a retrospective period.

STUDY DESIGN

Patients were prospectively enrolled in a multicenter study from seven institutions in the United States and Canada. Inclusion criteria were patients two months to 18 years of age with acute testicular torsion from March through July 2020. The retrospective group included patients from January 2019 through February 2020. Statistical analysis was performed using Kruskal-Wallis tests, Chi-square tests, and logistic regression.

RESULTS

A total of 221 patients were included: 84 patients in the COVID-19 cohort and 137 in the retrospective cohort. Median times from symptom onset to emergency department presentation during COVID-19 compared to the retrospective period were 17.9 h (IQR 5.5-48.0) and 7.5 h (IQR 4.0-28.0) respectively (p = 0.04). In the COVID-19 cohort, 42% of patients underwent orchiectomy compared to 29% of pre-pandemic controls (p = 0.06). During COVID-19, 46% of patients endorsed delay in presentation compared to 33% in the retrospective group (p = 0.04).

DISCUSSION

We found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a higher proportion of patients reported delaying care. Strengths of the study include the number of included patients and the multicenter prospective design during the pandemic. Limitations include a retrospective pre-pandemic comparison group.

CONCLUSIONS

In a large multicenter study we found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a significantly higher proportion of patients reported delaying care. Based on the findings of this study, more patient education is needed on the management of testicular torsion during a pandemic.

A multicenter study of acute testicular torsion in the time of COVID-19

BACKGROUND

Testicular torsion is a surgical emergency, and time to detorsion is imperative for testicular salvage. During the COVID-19 pandemic, patients may delay emergency care due to stay-at-home orders and concern of COVID-19 exposure.

OBJECTIVE

To assess whether emergency presentation for testicular torsion was delayed during the COVID-19 pandemic, and whether the rate of orchiectomy increased compared to a retrospective period.

STUDY DESIGN

Patients were prospectively enrolled in a multicenter study from seven institutions in the United States and Canada. Inclusion criteria were patients two months to 18 years of age with acute testicular torsion from March through July 2020. The retrospective group included patients from January 2019 through February 2020. Statistical analysis was performed using Kruskal-Wallis tests, Chi-square tests, and logistic regression.

RESULTS

A total of 221 patients were included: 84 patients in the COVID-19 cohort and 137 in the retrospective cohort. Median times from symptom onset to emergency department presentation during COVID-19 compared to the retrospective period were 17.9 h (IQR 5.5-48.0) and 7.5 h (IQR 4.0-28.0) respectively (p = 0.04). In the COVID-19 cohort, 42% of patients underwent orchiectomy compared to 29% of pre-pandemic controls (p = 0.06). During COVID-19, 46% of patients endorsed delay in presentation compared to 33% in the retrospective group (p = 0.04).

DISCUSSION

We found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a higher proportion of patients reported delaying care. Strengths of the study include the number of included patients and the multicenter prospective design during the pandemic. Limitations include a retrospective pre-pandemic comparison group.

CONCLUSIONS

In a large multicenter study we found a significantly longer time from testicular torsion symptom onset to presentation during the pandemic and a significantly higher proportion of patients reported delaying care. Based on the findings of this study, more patient education is needed on the management of testicular torsion during a pandemic.

Caregiver Burden Among Those Caring for Patients With Spina Bifida

OBJECTIVE

1) To identify baseline characteristics of caregivers of school-aged children with spina bifida; 2) To identify independent predictors of caregiver burden in this population.

MATERIALS AND METHODS

A survey was distributed via Facebook advertising to caregivers of patients with congenital genitourinary anomalies from May to September 2018. Eligible participants (n = 408) entailed English-speaking adults who are involved in the patient's care and attend ≥50% of their medical appointments. Caregiver burden was assessed using the Caregiver Burden Inventory (CBI), where higher scores indicate higher burden. CBI ≥24 indicates need for respite and CBI ≥36 indicates high risk of burnout. Bivariate analyses (t-tests and chi-square tests) were conducted using STATA software.

RESULTS

Our analysis includes 408 caregivers caring for patients with spina bifida. In our study population, 59.3% of caregivers were in need of respite due to caregiver burden and 26.7% of caregivers were so burdened that they are at risk of burning out (CBI score ≥36). Bivariate analysis showed that caregiver gender and number of tasks performed by the caregiver were significantly associated with risk of burnout (CBI ≥ 36). Multivariable analysis of overall caregiver burden showed increased risk of burnout (CBI ≥ 36) among older caregivers, female caregivers, and those performing more caregiving tasks.

CONCLUSION

Caregiver burden is common among caregivers of patients with spina bifida, and further research is needed to identify strategies and resources for mitigating caregiver burden.

Characteristics Associated With Depression, Anxiety, and Social Isolation in Adults With Spina Bifida

OBJECTIVE

To identify demographic and clinical characteristics associated with depression, anxiety, and social isolation among adults with spina bifida. We hypothesize that lower urinary tract dysfunction is associated with poor psychosocial outcomes.

METHODS

An anonymous survey was distributed via Facebook advertising to individuals with congenital urologic conditions. Adults with spina bifida were included in our analysis. Lower urinary tract dysfunction was assessed with the Neurogenic Bladder Symptom Score. Depression, anxiety, and social isolation T-scores were measured using Patient-Reported Outcome Measures Information System instruments. A composite depression-anxiety score was calculated. Separate adjusted linear models assessed the association between lower urinary tract dysfunction and depression, anxiety, composite depression-anxiety, and social isolation.

RESULTS

Around 195 participants were included. Rates of depression, anxiety, and social isolation were 48%, 47%, and 43%, respectively. Comorbid depression and anxiety occurred in 39% of subjects. On adjusted regression analysis, lower urinary tract dysfunction was associated with depression (P < 001), anxiety (P <.001), composite depression-anxiety (P <.001), and social isolation (P = .010).

CONCLUSION

Depression, anxiety, and social isolation are common in individuals with spina bifida relative to the general population, and associated with lower urinary tract dysfunction. Interventions focused on optimizing lower urinary tract symptoms and function, transition-age adults, group psychotherapy, and comorbid depression and anxiety may be of particular value in this population.

Demographics and baseline care among newly transitioning adult congenital urology patients

INTRODUCTION

In 2017, UCSF established a formal Transitional Urology (TU) clinic co-run by pediatric and adult urology aimed at providing comprehensive urologic care for people progressing into adulthood with complex urologic histories.

OBJECTIVE

We aim to describe baseline demographic and disease characteristics of this population, understand gaps in care, and gauge follow-through.

STUDY DESIGN

We performed a retrospective chart review of all new patients in the TU clinic at UCSF from February 2017 through January 2019. After approval from an institutional review board, demographic and clinical data were collected from medical records.

RESULTS

39 new patients were seen in UCSF's TU clinic during a 23-month period. Our cohort included 20 patients with spina bifida and neurogenic bladder, 5 with bladder exstrophy, 3 with disorders of sexual development (DSD), 5 with obstructive uropathy, 2 with cloacal anomalies, and 1 patient each with calcinuria, reflux nephropathy, prune belly syndrome, and urachal cyst. Mean age of patients was 26 years, 63% were male, 88% spoke English, and 70% had public insurance. Patients lived an average of 94 miles from the clinic and had a mean zipcode-based household income of $70,110. There was an average of 19 months between the initial TU visit and the most recent prior urology visit. The median time since last creatinine as well as last renal ultrasound was 9 months. 19 (54%) patients warranted a total of 28 referrals to other providers at their initial visit, and 42% of these were obtained within 6 months.

DISCUSSION

According to our demographic data, TU patients are likely to have public insurance, live far from the TU clinic, and come from low SES backgrounds. At initial presentation over half of patients warranted updated tests like creatinine and renal ultrasound. Furthermore, nearly two-thirds of patients required at least one referral to a different provider, suggesting a majority of these patients had unmet medical needs at the time of presentation to the TU clinic.

CONCLUSION

Our data indicate that new patients to the TU clinic often warrant additional workup, updated testing, and referrals to sub-specialty care as these needs are often unmet at the time of presentation. The etiology of this is unclear and it may be due to insurance difficulties, inability to identify an appropriate adult subspecialty provider or access to care issues. Further investigation into barriers to implementation of transitional care is needed to provide comprehensive management to this challenging patient population.

Cost-Effectiveness of Screening Ultrasound after a First, Febrile Urinary Tract Infection in Children Age 2-24 Months

OBJECTIVE

To estimate the cost-effectiveness of routine, screening renal bladder ultrasound (RBUS) for children age 2-24 months after a first febrile urinary tract infection (UTI), as recommended by the American Academy of Pediatrics.

STUDY DESIGN

We developed a decision analytic model that simulates a population of children after a first febrile UTI. The model incorporates the diagnostic utility of RBUS to detect vesicoureteral reflux and genitourinary anomalies. We adopted a health-system perspective, 5-year horizon, and included 1-way and 2-way sensitivity analyses. Costs were inflated to 2018 US dollars, and our model incorporated a 3% discounting rate. We compared routine RBUS after first, febrile UTI compared with routine RBUS after second UTI (ie, control arm). Our main outcomes were recurrent UTI rate and incremental cost per quality-adjusted life-year (QALY).

RESULTS

Among children 2-24 months after a first febrile UTI, RBUS had an overall accuracy (true positives + true negatives) of 64.4%. The recurrent UTI rate in the intervention arm was 19.9% compared with 21.0% in the control arm. Thus, 91 patients would need to be screened with RBUS to prevent 1 recurrent UTI. RBUS increases QALYs by +0.0002 per patient screened, corresponding to an incremental cost-effectiveness ratio of $803 000/QALY gained. In the RBUS arm, 20.6% of children would receive unnecessary voiding cystourethrograms compared with 12.2% of children in the control group.

CONCLUSIONS

Screening RBUS after a first, febrile UTI in children age 2-24 months does not meet cost-effectiveness guidelines. Our findings support deferred screening until a second UTI.

Eating disorders and disordered eating behaviors among women: Associations with sexual risk

OBJECTIVE

To evaluate the association between eating disorders or disordered eating behaviors and sexual risk in young women.

METHOD

We used prospective cohort data of young women ages 18-26 years from the National Longitudinal Study of Adolescent to Adult Health (N = 5,899). Exposures of interest (at 18-26 years) included a self-reported eating disorder diagnosis or disordered eating behaviors including fasting/skipping meals, vomiting, diet pills, or laxative/diuretic use to lose weight and binge eating. Sexual risk outcomes at 7-year follow-up included the number of new sexual partners, condom use, and sexually transmitted infections.

RESULTS

Having either an eating disorder or reporting any disordered eating behavior was associated with a greater number of new sexual partners (B = 1.09, 95% CI [0.18, 2.00]) and lower odds of condom use (odds ratio 0.70, 95% CI [0.53, 0.94] among a subsample of sexually active, unmarried women).

DISCUSSION

Young women with eating disorders or who engage in disordered eating behaviors are at higher risk for multiple new sexual partners and unprotected sex. Clinicians caring for young adults with eating disorders may consider screening for sexual risk behaviors.

Antimicrobial prophylaxis for urinary tract infections: implications for adherence assessment

BACKGROUND

Continuous antimicrobial prophylaxis (prophylaxis) is associated with a reduction in recurrent urinary tract infections in children with vesicoureteral reflux. However, adherence to daily medications has been shown to be poor.

OBJECTIVE

To determine patient/caregiver factors associated with non-adherence and to determine whether adherence alters the effect of prophylaxis on recurrent UTIs and renal scarring.

STUDY DESIGN

We conducted a secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux trial. We stratified adherence scores into quartiles to assess trends within the data. We assessed predictors of non-adherence using ordinal logistic regression. We then examined the efficacy of prophylaxis stratified by adherence quartiles.

RESULTS

Six hundred patients were included in the analysis. The quartiles of adherence were as follows: 1st quartile-0-70% adherence; 2nd quartile-71-91% adherence; 3rd quartile-92-96% adherence; and 4th quartile->96% adherence. Neither demographic factors nor disease severity was associated with non-adherence. In the subanalysis of patients who were toilet trained at baseline, increasing bladder and bowel dysfunction (BBD) symptom score was associated with non-adherence (adjusted odds ratio, aOR = 1.1, 95% confidence interval [CI] 1.0-1.2). Patients least adherent were 2.5 times more likely (95%CI 1.1-5.6) to have a recurrent UTI compared with patients most adherent. After controlling for treatment arm, age, sex, degree of reflux, BBD, and number of UTIs, patients least adherent (taking the study medication less than <70% of the time) were at highest risk for renal scarring (aOR = 24.2, 95%CI 3.0-197). In contrast, among the most adherent quartile, the probability of renal scarring was highest in those assigned prophylaxis (16.2% compared with 1.7% in those most adherent to placebo).

CONCLUSIONS

Adherence is distinctly related to clinical outcomes in children with VUR. Non-adherence is common and represents a distinct clinical entity that is associated with renal scarring. Adherence should be assessed in prophylaxis management algorithms.

Long-term follow-up of urethral reconstruction for blunt urethral injury at a young age: urinary and sexual quality of life outcomes

INTRODUCTION

Little is known about long-term patient-reported outcomes following surgical repair for pediatric blunt urethral trauma.

OBJECTIVE

The purpose was to evaluate long-term urinary outcomes, sexual function, and quality of life (QOL) of patients who undergo urethroplasty for blunt urethral trauma in childhood.

STUDY DESIGN

After IRB approval, we retrospectively reviewed the records of patients who sustained blunt urethral injury at ≤18 years and underwent urethroplasty at our institution between 1978 and 2013. We then used a web-based survey to assess urinary/sexual/ejaculatory function and overall QOL using validated questionnaires.

RESULTS

Of 68 eligible patients, 15 were able to be contacted (table). Median age of injury, age at urethroplasty, and age at follow-up were 17 (4-18), 17 (5-20), and 19 (13.5-21.5) years, respectively. The stricture was membranoprostatic in eight and bulbar in seven patients, with median length of 2 (1.6-2.6) cm. Excision/primary anastomosis was performed in all but three patients who required a buccal graft. Overall, 80% were 'very satisfied' and 20% were 'satisfied' with surgery. One patient reported a subsequent urethral intervention. On urethral stricture surgery patient-reported outcome measurement, the median bother (0 least, 24 worst) was 10 (8-12.5). The force of urine stream (1 strongest, 4 weakest) was 2 (1.5-2), with no report of urinary incontinence. The median Sexual Health Inventory for Men score (0 worst, 25 perfect) was 24 (22.5-24). The median ejaculatory function score (0 worst, 15 normal) was 14 (13-14.75). Six patients had fathered children and none reported infertility. Three patients reported <30° penile curvature not interfering with sex. Median QOL (0 worse, 10 best) was 8 (7.5-8).

CONCLUSIONS

Urethroplasty after blunt urethral injury in young adult population is associated with a high long-term success rate with a low rate of long-term urinary and sexual consequences in adulthood.

Predictors of becoming overweight among pediatric patients at risk for urinary tract infections

BACKGROUND

The association between obesity and urinary dysfunction in childhood has been described, albeit through retrospective analysis, making temporal relationships difficult to establish.

OBJECTIVE

The objective of this study was to determine risk factors for significant weight gain in children at risk for recurrent urinary tract infections.

STUDY DESIGN

A secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation trials was conducted. The outcome of interest in these children was significant increase in body mass index (BMI) percentile (>85th BMI percentile for sex and age) in previously normal-weight children. Multivariable logistic regression was used to determine the independent effects of predetermined risk factors.

RESULTS

In total, 446 patients were included in the study. Most patients aged less than 1 year at study entry (229, 51%), and 399 (89%) of patients were female. Eighty-four patients (17%) became clinically overweight. Patients assigned to prophylactic antibiotics were not more likely to gain significant BMI percentiles (adjusted odds ratio [aOR] = 1.1, 95% confidence interval [CI]=0.6-1.8). Significant BMI percentiles were gained in Hispanic/Latino patients compared with whites (aOR = 3.3, 95% CI=1.7-6.4), in children who were infants at study enrollment compared with non-infants (aOR = 2.1, 95% CI=1.2-3.8), and in those with persistent reflux during the study period (aOR = 2.1, 95% CI=1.0-4.3). Neither patients assigned to prophylactic antibiotics (aOR = 1.1, 95% CI=0.6-1.8) nor patients with bladder and bowel dysfunction (BBD) (aOR = 1.2, 95% CI=0.6-2.3) were more likely to gain significant BMI percentiles.

DISCUSSION

Significant BMI percentile gain is common in patients at risk for UTIs. Hispanic/Latino ethnicity, persistent reflux, and younger age, specifically infants than non-infants, were identified as independent risk factors for becoming overweight in this population. Exposure to prophylactic antibiotics and BBD were not associated with becoming overweight.

CONCLUSION

Risk for becoming overweight should be discussed when managing patients at risk for UTIs, especially in the subpopulations identified.

Uropathogen Resistance and Antibiotic Prophylaxis: A Meta-analysis

CONTEXT

Limited data exist regarding uropathogen resistance in randomized controlled trials of urinary tract infection (UTI) prevention and antibiotic prophylaxis.

OBJECTIVE

To assess the effect of prophylaxis on developing a multidrug-resistant first recurrent UTI among children with vesicoureteral reflux.

DATA SOURCES

Cochrane Kidney and Transplant Specialized Register through May 25, 2017.

STUDY SELECTION

Randomized controlled trials of patients ≤18 years of age with a history of vesicoureteral reflux being treated with continuous antibiotic prophylaxis compared with no treatment or placebo with available antibiotic sensitivity profiles.

DATA EXTRACTION

Two independent observers abstracted data and assessed quality and validity per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Adjusted meta-analyses were performed by using a mixed-effects logistic regression model.

RESULTS

One thousand two hundred and ninety-nine patients contributed 224 UTIs. Patients treated with prophylaxis were more likely to have a multidrug-resistant infection (33% vs 6%, P < .001) and were more likely to receive broad-spectrum antibiotics (68% vs 49%, P = .004). Those receiving prophylaxis had 6.4 times the odds (95% confidence interval: 2.7-15.6) of developing a multidrug-resistant infection. One multidrug-resistant infection would develop for every 21 reflux patients treated with prophylaxis.

LIMITATIONS

Variables that may contribute to resistance such as medication adherence and antibiotic exposure for other illnesses could not be evaluated.

CONCLUSIONS

Prophylaxis increases the risk of multidrug resistance among recurrent infections. This has important implications in the risk-benefit assessment of prophylaxis as a management strategy and in the selection of empirical treatment of breakthrough infections in prophylaxis patients.

Risk Factors for the Development of Bladder and Bowel Dysfunction

BACKGROUND

Patients with vesicoureteral reflux and concomitant bladder and bowel dysfunction (BBD) are at high risk for febrile urinary tract infections. Risk factors for BBD have been identified in retrospective studies without validated measures.

METHODS

We conducted a secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation trials. The outcome of interest in the analysis of these children was the development of BBD, defined by using the dysfunctional voiding questionnaire, during any time point in the studies. We used multivariable logistic regression to determine the independent effects of sex, baseline percentile BMI, cohort status (Randomized Intervention for Children with Vesicoureteral Reflux versus Careful Urinary Tract Infection Evaluation), continuous antibiotic prophylaxis (yes or no), and reflux status (dilating versus nondilating) on the development of BBD.

RESULTS

Three hundred and eighteen patients met inclusion criteria. The majority of patients (244 patients, 77%) were not toilet trained at baseline visit. The median baseline age (interquartile range) was 21 months (11-35 months), and 299 (94%) patients were girls. During the study period, 111 (35%) developed BBD. Baseline BMI percentile was not associated with BBD development (adjusted odds ratio [aOR] = 1.0; 95% confidence interval [CI]: 0.9-1.1), whereas female sex was highly associated with BBD development (aOR = 12.7; 95% CI: 1.6-98). Patients with dilating reflux at baseline were 2.1 times more likely to develop BBD (95% CI: 1.2-3.7). Antibiotic prophylaxis was not associated with BBD development (aOR = 0.8; 95% CI: 0.4-1.4).

CONCLUSIONS

Dilating reflux and female sex were identified as risk factors for development of BBD, but neither BMI nor prophylactic antibiotics was associated with the development of BBD.

Management of Pediatric Grade IV Renal Trauma

PURPOSE OF REVIEW

Review the current literature regarding the management of grade IV renal injuries in children.

RECENT FINDINGS

Children are at increased risk for renal trauma compared to adults due to differences in anatomy. Newer grading systems have been proposed and are reviewed. Observation of most grade IV renal injuries is safe. Operative intervention is necessary for the unstable patient to control life-threatening bleeding with either angioembolization or open exploration. Symptomatic urinomas may require percutaneous drainage and/or endoscopic stent placement. Ureteropelvic junction (UPJ) disruption, seen more often in children, requires immediate surgical repair. Grade IV renal injuries in children are increasingly managed in a conservative manner.

Does perception of catheterization limit its use in pediatric UTI?

INTRODUCTION

Urinary tract infections (UTIs) affect 3-8% of febrile children annually, but correctly diagnosing UTI in young children can present a challenge. Diagnosis requires a non-contaminated urine sample, which requires catheterization or suprapubic aspiration in infants and young children that have not completed toilet training. To improve adherence to these guidelines, it is critical to understand the barriers to urine testing and catheterization.

OBJECTIVE

The purpose of this study was to investigate parental perception of pediatric UTI evaluation to better understand factors that impede urine testing prior to treatment of suspected UTI.

STUDY DESIGN

We conducted an electronic, cross-sectional survey via social media targeting parents of children with a history of UTI. Participants were queried regarding demographics, urine specimen collection method, factors influencing urine collection method, and perception of the experience. Multivariable logistic regression was used to assess factors associated with catheterization distress and urine testing.

RESULTS

Of 2726 survey respondents, > 80% were female and White; 74% of the children with a history of UTI were female. Fifty-six percent of parents perceived extreme distress with catheterization. Among parents whose child was catheterized, extreme distress was less likely perceived if the parent was White (OR 0.6, 95% CI 0.4-0.9) or if the child was circumcised (OR 0.7, 95% CI 0.4-0.98). Among those whose child was not catheterized, extreme distress was more likely if parents had a college education (OR 3.2, 95% CI 2.2-4.5) and the child was more than 1 year old (OR 1.7, 95% CI 1.2-2.5). Catheterization was less likely to be withheld if parents had a college education (OR 0.1, 95% CI 0.1-0.2), and if the child was circumcised (OR 0.5, 95% CI 0.3-0.8) or had only one UTI (OR 0.6, 95% CI 0.4-0.8) (Table).

DISCUSSION

Parental education level, child age, and circumcision status play an important role in the subjective distress associated with catheterization. This highlights the substantial impact of parental factors on adherence to guidelines for children suspected of UTI. For example, college-educated parents were more likely to be offered catheterization. However, these parents are also more likely to associate the catheterization experience with extreme distress, possibly limiting their likelihood of consent to this procedure. More studies are required to better understand the impact of these factors on catheterization. But, it is clear that parental input has a substantial impact on the evaluation of their child's suspected UTI.

Parental Preference Assessment for Vesicoureteral Reflux Management in Children

PURPOSE

Parents of children with vesicoureteral reflux are presented with a variety of management options, which in many cases offer a similar risk-benefit ratio. To facilitate shared decision making, parental preferences regarding vesicoureteral reflux treatment options need to be acknowledged. We aimed to characterize the clinical experience of parents and elicit core themes affecting decision making in regard to managing vesicoureteral reflux in their child.

MATERIALS AND METHODS

A semistructured, qualitative interview script was developed and vetted by 25 pediatric urologists to discuss treatment options for vesicoureteral reflux. Additional patient interviews were conducted until new themes failed to arise. Content analysis was performed to extract all statements that described treatment options. Similar statements were combined until a final list of unique themes emerged.

RESULTS

A total of 26 interviews were performed, yielding 689 statements about overall parent experiences with managing vesicoureteral reflux in the child and 450 statements (65%) pertaining to treatment options. Of the 13 themes that emerged, those most commonly considered were the prevention of future urinary tract infections by 85% of parents, the efficacy rate of treatment options by 85%, the burden of daily maintenance or compliance by 77%, antibiotic resistance by 69%, chronic kidney damage by 62% and invasiveness by 58%.

CONCLUSIONS

Our study emphasizes that when choosing a treatment option for vesicoureteral reflux in their child, parent preferences regarding risks and benefits are variable. However, their chief concerns include whether a method decreases the risk of urinary tract infections, has an acceptable efficacy rate and aligns itself with the capabilities of the family. These themes help frame discussions between families and clinicians regarding vesicoureteral reflux management, and they can facilitate shared decision making.

State appellant cases for testicular torsion: Case review from 1985 to 2015

OBJECTIVE

Testicular torsion is one of the most common diagnoses involved in lawsuits in the pediatric patient. Missed diagnosis and diagnostic delays put patients at risk for testicular loss and have resulted in malpractice litigation. Using a national database, we sought to describe testicular torsion malpractice cases tried at the state and federal level and investigate factors associated with successful defense by the provider.

METHOD

We reviewed the Lexis Nexis academic legal database. We searched all cases using the terms "testicular torsion" and "medical malpractice" from 1985 to 2015. From this search, we compiled various medical and legal aspects of the case including the outcome of the trial. We performed multivariate logistic regression to determine which factors were associated with successful defense at the state level.

RESULTS

Fifty-three malpractice cases of testicular torsion were included. State appeals were in favor of providers in 26 (50%) of cases. The average time between initial presentation of the patient and the state verdict decision was 5 years. Emergency room (ER) physicians were the most common provider sued (35%). Approximately half of the patients (26, 51%) first presented to the ER, and atypical presentations were common, as 16 (31%) presented with abdominal pain only. The proportion of patients with false-negative ultrasounds was 16 of 25 (64%). If the patient first presented to the ER, the doctor was less likely to have a successful defense (OR = 0.23; 95% CI 0.06-0.79]). Most verdicts (8/9, 89%) were in favor of urologists. One urologist lost at the state level because of delayed time to the operating room.

CONCLUSIONS

Atypical clinical presentations and false-negative ultrasound findings are common in testicular torsion malpractice litigation at the state and federal level. Providers who used ultrasound were not more likely to win the state appeal, and providers whose patients presented to the ER were less likely to have a successful defense. Although 50% of providers won the state appeal, the time from initial patient presentation and final state verdict decision was substantial.

Determinants of practice patterns in pediatric UTI management

INTRODUCTION

Urinary tract infection (UTI) affects 10% of girls and 3% of boys by age 16. Both the American Academy of Pediatrics and National Institute for Health and Clinical Excellence Guidelines recommend urine testing prior to initiation of antibiotic treatment and the use of local antibiograms to guide empiric antibiotic therapy. Urine culture results not only provide the opportunity to halt empiric therapy if there is no bacterial growth, but also allow for tailoring of broad-spectrum therapy. Additionally, the use of antiobiograms improves empiric antibiotic selection based on local resistance patterns. However, execution of guideline recommendations has proved challenging. Understanding barriers in implementation is critical to developing targeted interventions aimed to improve adherence to these guidelines.

OBJECTIVES

The present study sought to investigate practice patterns and factors that influence urine testing and antibiogram use in the setting of empiric antibiotic treatment of UTI in children to ultimately improve adherence to UTI management guidelines.

STUDY DESIGN

A random, national sample of physicians caring for children was surveyed from the American Medical Association Masterfile. Participants were queried regarding practice type, length of time in practice, factors influencing urine testing, urine specimen collection method, and antibiogram utilization. Logistic regression was used to assess factors associated with use of urine testing, bagged specimens, and antibiograms.

RESULTS

Of respondents who acknowledged contact by surveyors, 47% completed the survey (n = 366). Most respondents (84%) obtain urinalysis and culture prior to treatment for UTI. Physicians report they would more likely order testing if the specimen were easier to collect (46%) and if results were available immediately (48%) (Table). Urine collection by bag was more common in circumcised boys (>30%) compared with girls (20%) and uncircumcised boys (20%) (P = 0.02). The most common reasons for collection by bag were parental refusal for (49%) and difficulty with (42%) catheterization (Table). Of the 70% of respondents reporting antibiogram access (n = 256), 50% report its use the majority of the time with empiric prescription (n = 128).

DISCUSSION

While most practitioners report following guidelines to obtain urine testing prior to antibiotic prescription for UTI, urine collection by bag is common. Additionally, <50% of practitioners adhere to guideline recommendations for empiric antibiotic selection based on local antibiograms. Interventions to improve adherence to UTI management guidelines should focus on (1) improving catheterization practices, (2) educating parents regarding the value of catheterization, and (3) incorporating local antibiograms into electronic medical records.

Do adult men with untreated ventral penile curvature have adverse outcomes?

INTRODUCTION

Congenital ventral penile curvature without hypospadias is often treated surgically in childhood. The history of untreated ventral curvature is unknown.

OBJECTIVE

This study's aim was to examine the association of untreated ventral penile curvature with various sexual and psychosexual outcomes.

STUDY DESIGN

An electronic survey was advertised to men older than 18 years on Facebook. Men with possible ventral penile curvature identified themselves by choosing sketches that most closely represented their anatomy. Outcomes assessed included: Sexual Health Inventory for Men, difficulty of intercourse because of curvature, International Prostate Symptom Score, Penile Perception Score, psychosexual milestones, paternity, infertility, sitting to urinate, and the CDC HRQOL-4 module.

RESULTS

Among participants, 81 out of 684 men (11.8%) reported untreated ventral penile curvature. Participants with self-reported curvature noted more difficulty with intercourse because of curvature (4.5 vs 4.9, p < 0.001), more unhealthy mental days (8.6 vs 6.2, p = 0.02), and increased dissatisfaction with penile self-perception compared with men without reported curvature (8.6 vs 9.5, p < 0.001).

DISCUSSION

Men with possible untreated ventral curvature reported worse penile perception scores, more mentally unhealthy days, and increased difficulty with intercourse secondary to curvature compared with men without curvature. A limitation to this study is selection bias; responses collected were self-reported from survey volunteers. Additionally, the question identifying ventral penile curvature is not validated but performed well in pretesting. Most questions were from validated surveys, but some were modeled after validated surveys and/or contained high face validity types of questions.

CONCLUSION

Men with possible untreated ventral penile curvature reported more dissatisfaction with penile appearance, increased difficulty with intercourse, and more unhealthy mental days. Given high success rates, low complications, and improved outcomes after surgical correction of penile curvature reported in the literature, our results support correction of congenital penile curvature in childhood.

Work-up of Pediatric Urinary Tract Infection

Pediatric urinary tract infection (UTI) costs the health care system more than $180 million annually, and accounts for more than 1.5 million clinician visits per year. Accurate and timely diagnosis of these infections is important for determining appropriate treatment and preventing long-term complications such as renal scarring, hypertension, and end-stage renal disease. After the first 12 months, girls are more likely to be diagnosed with a UTI. About half of boys with UTI are diagnosed within the first 12 months of life. Diagnosis of UTI is made based on history and examination findings and confirmed by urine testing.

Scrotal swelling in the neonate

Discovery of scrotal swelling in a neonate can be a source of anxiety for parents, clinicians, and sonologists alike. This pictorial essay provides a focused review of commonly encountered scrotal masses and mimics specific to the neonatal setting. Although malignancy is a concern, it is very uncommon, as most neonatal scrotal masses are benign. Key discriminating features and management options are highlighted to improve the radiologist's ability to diagnose neonatal scrotal conditions and guide treatment decisions. Neonatal scrotal processes ranging from common to uncommon will be discussed.

Cumulative incidence of outcomes and urologic procedures after augmentation cystoplasty

OBJECTIVE

Augmentation cystoplasty (AC) is a major surgery that can be associated with long-term morbidity. This study aimed to describe the cumulative incidence of outcomes and urologic procedures in a large cohort of children who underwent AC, identify significant sources of morbidity, and to evaluate baseline factors associated with outcomes of interest.

METHODS

Children≤18 years who underwent AC in the Pediatric Health Information System from 1999 to 2010 were included. All follow-up encounters up to June 2012 were included. Cumulative incidences for 15 outcomes and urologic procedures were calculated using non-informative censoring. Sensitivity analyses were performed to determine effect of censoring assumptions and including hospitals without complete datasets. As an exploratory analysis, baseline patient factors were evaluated for associations with outcomes and urologic procedures of interest using multivariable Cox proportional hazards models adjusted for clustering by hospital.

RESULTS

2831 AC patients were identified. Based on cumulative incidence calculations and sensitivity analyses; the cumulative incidence ranges of outcomes and procedures at 1, 3, 5, and 10 years were calculated. Examples of 10-year cumulative incidence ranges are given for the following outcomes and procedures: bladder rupture (2.9-6.4%), small bowel obstruction (5.2-10.3%), bladder stones (13.3-36.0%), pyelonephritis (16.1-37.1%), cystolithopaxy (13.3-35.1%), and reaugmentation (5.2-13.4%). The development of chronic kidney disease was strongly associated with a diagnosis of lower urinary tract obstruction (HR 13.7; 95% CI 9.4-19.9). Bladder neck surgery and stoma creation at time of AC were associated with an increased hazard of bladder rupture (HR 1.9; 95% CI 1.1-3.3) and bladder stones (HR 1.4; 95% CI 1.1-1.8) respectively.

CONCLUSIONS

Outcomes of interest and urologic procedures after AC are common. Results from this large cohort can be used to counsel patients and families about expectations after AC. Pyelonephritis, chronic kidney disease, further reconstructive surgery, and calculus disease appear to cause significant morbidity. Collaborative efforts are needed to further reduce morbidity in this patient population.

Antibiotic resistance in pediatric urology

Antibiotics are a mainstay in the treatment of bacterial infections, though their use is a primary risk factor for the development of antibiotic resistance. Antibiotic resistance is a growing problem in pediatric urology as demonstrated by increased uropathogen resistance. Lack of urine testing, nonselective use of prophylaxis, and poor empiric prescribing practices exacerbate this problem. This article reviews antibiotic utilization in pediatric urology with emphasis on modifiable practice patterns to potentially help mitigate the growing rates of antibiotic resistance. This includes urine testing to only treat when indicated and tailor broad-spectrum therapy as able; selective application of antibiotic prophylaxis to patients with high-grade vesicoureteral reflux and hydronephrosis with counseling regarding the importance of compliance; and using local antiobiograms, particularly pediatric-specific antiobiograms, with inpatient versus outpatient data.

A comparison of inpatient versus outpatient resistance patterns of pediatric urinary tract infection

PURPOSE

Prior single center studies showed that antibiotic resistance patterns differ between outpatients and inpatients. We compared antibiotic resistance patterns for urinary tract infection between outpatients and inpatients on a national level.

MATERIALS AND METHODS

We examined outpatient and inpatient urinary isolates from children younger than 18 years using The Surveillance Network (Eurofins Scientific, Luxembourg, Luxembourg), a database of antibiotic susceptibility results, as well as patient demographic data from 195 American hospitals. We determined the prevalence and antibiotic resistance patterns of the 6 most common uropathogens, including Escherichia coli, Proteus mirabilis, Klebsiella, Enterobacter, Pseudomonas aeruginosa and Enterococcus. We compared differences in uropathogen prevalence and resistance patterns for outpatient and inpatient isolates using chi-square analysis.

RESULTS

We identified 25,418 outpatient (86% female) and 5,560 inpatient (63% female) urinary isolates. Escherichia coli was the most common uropathogen overall but its prevalence varied by gender and visit setting, that is 79% of uropathogens overall for outpatient isolates, including 83% of females and 50% of males, compared to 54% for overall inpatient isolates, including 64% of females and 37% of males (p <0.001). Uropathogen resistance to many antibiotics was lower in the outpatient vs inpatient setting, including trimethoprim/sulfamethoxazole 24% vs 30% and cephalothin 16% vs 22% for E. coli (each p <0.001), cephalothin 7% vs 14% for Klebsiella (p = 0.03), ceftriaxone 12% vs 24% and ceftazidime 15% vs 33% for Enterobacter (each p <0.001), and ampicillin 3% vs 13% and ciprofloxacin 5% vs 12% for Enterococcus (each p <0.001).

CONCLUSIONS

Uropathogen resistance rates of several antibiotics are higher for urinary specimens obtained from inpatients vs outpatients. Separate outpatient vs inpatient based antibiograms can aid in empirical prescribing for pediatric urinary tract infections.

Secondary data analysis of large data sets in urology: successes and errors to avoid

PURPOSE

Secondary data analysis is the use of data collected for research by someone other than the investigator. In the last several years there has been a dramatic increase in the number of these studies being published in urological journals and presented at urological meetings, especially involving secondary data analysis of large administrative data sets. Along with this expansion, skepticism for secondary data analysis studies has increased for many urologists.

MATERIALS AND METHODS

In this narrative review we discuss the types of large data sets that are commonly used for secondary data analysis in urology, and discuss the advantages and disadvantages of secondary data analysis. A literature search was performed to identify urological secondary data analysis studies published since 2008 using commonly used large data sets, and examples of high quality studies published in high impact journals are given. We outline an approach for performing a successful hypothesis or goal driven secondary data analysis study and highlight common errors to avoid.

RESULTS

More than 350 secondary data analysis studies using large data sets have been published on urological topics since 2008 with likely many more studies presented at meetings but never published. Nonhypothesis or goal driven studies have likely constituted some of these studies and have probably contributed to the increased skepticism of this type of research. However, many high quality, hypothesis driven studies addressing research questions that would have been difficult to conduct with other methods have been performed in the last few years.

CONCLUSIONS

Secondary data analysis is a powerful tool that can address questions which could not be adequately studied by another method. Knowledge of the limitations of secondary data analysis and of the data sets used is critical for a successful study. There are also important errors to avoid when planning and performing a secondary data analysis study. Investigators and the urological community need to strive to use secondary data analysis of large data sets appropriately to produce high quality studies that hopefully lead to improved patient outcomes.

Use of urine testing in outpatients treated for urinary tract infection

OBJECTIVE

To characterize urine test use in ambulatory, antibiotic-treated pediatric urinary tract infection (UTI).

METHODS

We studied children <18 years who had an outpatient UTI and a temporally associated antibiotic prescription from 2002 through 2007 by using a large claims database, Innovus i3. We evaluated urine-testing trends and performed multivariable logistic regression to assess for factors associated with urine culture use.

RESULTS

Of 40 603 treated UTI episodes in 28 678 children, urinalysis was performed in 76%, and urine culture in 57%; 32% of children <2 years had no urinalysis or culture performed for an antibiotic-treated UTI episode. Urine culture use decreased during the study period from 60% to 54% (P < .001). We observed variation in urine culture use with age (<2 years: odds ratio [OR] 1.0, 95% confidence interval [CI] 0.9-1.1; 2-5 years: OR 1.3, 95% CI 1.2-1.4; 6-12 years: OR 1.3, 95% CI 1.2-1.4, compared with 13-17 years); gender (boys: OR 0.8, 95% CI 0.8-0.9); and specialty (pediatrics: OR 2.6, 95% CI 2.5-2.8; emergency medicine, OR 1.2, 95% CI 1.1-1.3; urology: OR 0.5, 95% CI 0.4-0.6, compared with family/internal medicine). Recent antibiotic exposure (OR 1.1, 95% CI 1.1-1.2) and empirical broad-spectrum prescription (OR 1.2, 95% CI 1.1-1.2) were associated with urine culture use, whereas previous UTI and urologic anomalies were not.

CONCLUSIONS

Providers often do not obtain urine tests when prescribing antibiotics for outpatient pediatric UTI. Variation in urine culture use was observed based on age, gender, and physician specialty. Additional research is necessary to determine the implications of empirical antibiotic prescription for pediatric UTI without confirmatory urine testing.

Antibiotic resistance patterns of outpatient pediatric urinary tract infections

PURPOSE

We characterize the current national patterns of antibiotic resistance of outpatient pediatric urinary tract infection.

MATERIALS AND METHODS

We examined outpatient urinary isolates from patients younger than 18 years in 2009 using The Surveillance Network®, a database with antibiotic susceptibility results and patient demographic data from 195 United States hospitals. We determined the prevalence and antibiotic resistance patterns for the 6 most common uropathogens, ie Escherichia coli, Proteus mirabilis, Klebsiella, Enterobacter, Pseudomonas aeruginosa and Enterococcus. We compared differences in uropathogen prevalence between males and females using chi-square analysis.

RESULTS

We identified 25,418 outpatient urinary isolates. E. coli was the most common uropathogen overall but the prevalence of E. coli was higher among females (83%) than males (50%, p <0.001). Other common species among males were Enterococcus (17%), P. mirabilis (11%) and Klebsiella (10%). However, these uropathogens each accounted for 5% or less of female isolates (p <0.001). Resistance among E. coli was highest for trimethoprim-sulfamethoxazole (24%) but lower for nitrofurantoin (less than 1%) and cephalothin (15%). Compared to 2002 Surveillance Network data, E. coli resistance rates increased for trimethoprim-sulfamethoxazole (from 23% to 31% in males and from 20% to 23% in females) and ciprofloxacin (from 1% to 10% and from 0.6% to 4%, respectively).

CONCLUSIONS

E. coli remains the most common pediatric uropathogen. Although widely used, trimethoprim-sulfamethoxazole is a poor empirical choice for pediatric urinary tract infections in many areas due to high resistance rates. First-generation cephalosporins and nitrofurantoin are appropriate narrow-spectrum alternatives given their low resistance rates. Local antibiograms should be used to assist with empirical urinary tract infection treatment.

Diagnostic imaging in cryptorchidism: utility, indications, and effectiveness

BACKGROUND

Cryptorchidism (undescended testis) is the most common genitourinary anomaly in male infants.

METHODS

We reviewed the available literature on the diagnostic performance of ultrasound, computed tomography, and magnetic resonance imaging (MRI) in localizing undescended testes.

RESULTS

Ultrasound is the most heavily used imaging modality to evaluate undescended testes. Ultrasound has variable ability to detect palpable testes and has an estimated sensitivity and specificity of 45% and 78%, respectively, to accurately localize nonpalpable testes. Given the poor ability to localize nonpalpable testes, ultrasound has no role in the routine evaluation of boys with cryptorchidism. Magnetic resonance imaging has greater sensitivity and specificity but is expensive, not universally available, and often requires sedation for effective studies of pediatric patients. Diagnostic laparoscopy has nearly 100% sensitivity and specificity for localizing nonpalpable testes and allows for concurrent surgical correction.

CONCLUSIONS

Although diagnostic imaging does not have a role in the routine evaluation of boys with cryptorchidism, there are clinical scenarios in which imaging is necessary. Children with ambiguous genitalia or hypospadias and undescended testes should have ultrasound evaluation to detect the presence of müllerian structures.

Management trends in prenatally detected hydronephrosis: national survey of pediatrician practice patterns and antibiotic use

OBJECTIVE

To assess the practice patterns of general pediatricians in the management of prenatally detected hydronephrosis. Hydronephrosis is the most common abnormality found on prenatal ultrasonography. The utility of prophylactic antibiotics in the postnatal management of this condition is controversial. No study has assessed the practice patterns of general pediatricians in the management of prenatally detected hydronephrosis.

METHODS

An 18-question survey was sent to a random cross-section national sample of pediatricians from the American Medical Association Masterfile. The participants answered questions regarding practice location and type, practice experience, frequency of cases seen, familiarity with the published data, use of antibiotics, workup of hydronephrosis, and specialist referral. Multivariate logistic regression analysis was used to identify the factors associated with prescribing antibiotics.

RESULTS

Of the 461 pediatricians, 244 (53%) responded. Of the respondents, 56% routinely prescribed antibiotics for prenatally detected hydronephrosis, and 57% performed the postnatal workup themselves. Of these, 98% routinely ordered ultrasound scans and ∼40% routinely ordered voiding cystourethrograms. Of the respondents, 94% always had specialists readily available; however, only 41% always referred to a specialist. On multivariate logistic regression analysis, those who believe prophylactic antibiotics to be beneficial were significantly more likely to prescribe antibiotics than those who had not read the published data (odds ratio 6.1, 95% confidence interval 2-15). Those without specialist consultation readily available had an increased odds of starting prophylactic antibiotics compared with those who had consultation available (odds ratio 7.2, 95% confidence interval 1.3-39).

CONCLUSION

Most pediatricians initiate postnatal management of prenatally detected hydronephrosis; therefore, pediatricians truly are the gatekeepers for children with this condition. Knowledge of the practice patterns is crucial for the dissemination of evidence-based information to the appropriate providers and will enable us to learn more about the utility of antibiotic prophylaxis in future studies.

National ambulatory antibiotic prescribing patterns for pediatric urinary tract infection, 1998-2007

OBJECTIVE

The goal of this study was to investigate patterns of ambulatory antibiotic use and to identify factors associated with broad-spectrum antibiotic prescribing for pediatric urinary tract infections (UTIs).

METHODS

We examined antibiotics prescribed for UTIs for children aged younger than 18 years from 1998 to 2007 using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Amoxicillin-clavulanate, quinolones, macrolides, and second- and third-generation cephalosporins were classified as broad-spectrum antibiotics. We evaluated trends in broad-spectrum antibiotic prescribing patterns and performed multivariable logistic regression to identify factors associated with broad-spectrum antibiotic use.

RESULTS

Antibiotics were prescribed for 70% of pediatric UTI visits. Trimethoprim-sulfamethoxazole was the most commonly prescribed antibiotic (49% of visits). Broad-spectrum antibiotics were prescribed one third of the time. There was no increase in overall use of broad-spectrum antibiotics (P = .67); however, third-generation cephalosporin use doubled from 12% to 25% (P = .02). Children younger than 2 years old (odds ratio: 6.4 [95% confidence interval: 2.2-18.7, compared with children 13-17 years old]), females (odds ratio: 3.6 [95% confidence interval: 1.6-8.5]), and temperature ≥ 100.4°F (odds ratio: 2.9 [95% confidence interval: 1.0-8.6]) were independent predictors of broad-spectrum antibiotic prescribing. Race, physician specialty, region, and insurance status were not associated with antibiotic selection.

CONCLUSIONS

Ambulatory care physicians commonly prescribe broad-spectrum antibiotics for the treatment of pediatric UTIs, especially for febrile infants in whom complicated infections are more likely. The doubling in use of third-generation cephalosporins suggests that opportunities exist to promote more judicious antibiotic prescribing because most pediatric UTIs are susceptible to narrower alternatives.