Recurrent Urinary Tract Infections and Related Conditions

What Are UTIs?

Urinary tract infections (UTIs) happen when bacteria (germs) get into the kidneys, ureters, bladder, or urethra. UTIs are common in kids, especially girls and uncircumcised boys.

What Are Recurrent UTIs?

Some kids get UTIs again and again — these are called recurrent UTIs. If they're not treated, recurrent UTIs can cause kidney damage, especially in kids younger than 6. So it's important to know how to recognize the signs of these infections and get help for your child.

What Are the Signs & Symptoms of UTIs?

Symptoms of a UTI can include:

• pain when peeing
• changes in how often a child needs to pee
• changes in the look or smell of pee
• fever
• chills
• loss of appetite
• nausea
• vomiting
• lower belly pain
• lower back pain or discomfort

UTIs also can cause kids to wet their pants or the bed, even if they haven't had these problems before. Infants and very young children may only show nonspecific signs, such as fever, vomiting, or decreased appetite or activity.

What Are the Types of UTIs?

Common types of UTIs include:

• cystitis: this bladder infection is the most common type of UTI. It happens when bacteria move up the urethra (the tube-like structure that allows urine to exit the body from the bladder) and into the bladder.
• urethritis: when bacteria infect the urethra
• pyelonephritis: a kidney infection caused by infected urine flowing backward from the bladder into the kidneys or an infection in the bloodstream reaching the kidneys

What Conditions Are Related to Recurrent UTIs?

Recurrent UTIs sometimes happen along with other conditions, such as:

• vesicoureteral reflux (VUR), which is found in 30%–50% of kids diagnosed with a UTI. In this congenital (present at birth) condition, pee flows backward from the bladder to the ureters. Ureters are thin, tube-like structures that carry pee from the kidney to the bladder. Sometimes the pee backs up to the kidneys. If it's infected with bacteria, it can lead to pyelonephritis.
• hydronephrosis, which is an enlargement of one or both kidneys due to backup or blockage of urine flow. It's usually caused by severe VUR or a blocked ureter. Some kids with hydronephrosis might need to take daily low doses of antibiotics to prevent UTIs until the condition producing hydronephrosis gets better or is fixed through surgery.

But not all cases of recurrent UTIs can be traced back to these body structure-related problems. For example, dysfunctional voiding — when a child doesn't relax the muscles properly while peeing — is a common cause of UTIs. Not peeing often enough (infrequent urination) also can also increase a child's risk for recurrent infections. Both dysfunctional voiding and infrequent urination can be associated with constipation.

Rarely, unrelated conditions that harm the body's natural defenses, such as diseases of the immune system, also can lead to recurrent UTIs. Use of a nonsterile urinary catheter can introduce bacteria into the urinary tract and also cause an infection.

How Are Urinary Abnormalities Diagnosed?

It's important for a doctor to rule out any underlying problems in the urinary system when a child gets UTIs repeatedly. Kids with recurrent infections should see a pediatric urologist to see what is causing the infections.

Some problems can be found before birth. Hydronephrosis that develops before birth can be seen in an ultrasound as early as 16 weeks. In rare cases, doctors may consider neonatal surgery (surgery on an unborn baby) if hydronephrosis affects both kidneys and is a risk to the fetus. Most of the time, though, doctors wait until after birth to treat the condition, because almost half of all cases seen prenatally disappear by the time a baby is born.

Doctors will closely watch the blood pressure of a newborn thought to have hydronephrosis or another urinary system abnormality, because some kidney problems can cause high blood pressure. Another ultrasound may be done to get a closer look at the bladder and kidneys. If the condition appears to be affecting both kidneys, doctors usually will order blood tests to check kidney function.

Tests Done

If an abnormality of the urinary tract is suspected, doctors might order tests to make an accurate diagnosis, including:

Ultrasound

Using high-frequency sound waves to "echo," or bounce, off the body and create a picture of it, an ultrasound can find some problems in the kidneys, ureters, and bladder. It can also measure the size and shape of the kidneys.

When an ultrasound points to VUR or hydronephrosis, a renal scan or voiding cystourethrogram (VCUG) might give doctors a better idea of what's going on.

Renal scan (nuclear scan)

Radioactive material is injected into a vein and followed through the urinary tract. The material can show the shape of the kidneys, how well they function, if there is damaged kidney tissue, and the course of the urine. A small amount of radiation is received during the test and leaves the body in the urine.

Voiding cystourethrogram (VCUG or cystogram)

An opaque dye is injected into the bladder through a catheter (a hollow, soft tube). This X-ray test can diagnose VUR and identify problems with the bladder or urethra.

Contrast enhanced voiding ultrasonography (CeVUS)

Similar to a VCUG, the bladder is catheterized, then filled with a solution that can be seen using ultrasound instead of X-rays. If the solution appears near the kidneys, then reflux is present.

Cystoscopy

A cystoscope uses lenses and a light source within a tube inserted through the urethra to directly view the inside of the bladder. It's used when other tests or symptoms indicate a possible bladder abnormality.

Magnetic resonance urography (MR-U)

This procedure, which makes a magnetic resonance imaging (MRI) scan of the urinary tract without the use of dyes or radioactive materials, is as accurate as other scans and is now typically done in place of an intravenous pyelogram.

Intravenous pyelogram

Opaque dye is injected into a vein, and then X-rays are taken to follow the course of the dye through the urinary system. This test is still used sometimes, but the renal MRI and renal scan have replaced it in most cases.

How Are Recurrent UTIs Treated?

Treatment for recurrent UTIs depends on what's causing them. Sometimes the answer is as simple as teaching a child to empty their bladder as soon as they have the urge to go.

If a condition like VUR is causing the infections, the solution is a bit more complicated. Kids with VUR must be watched closely, because it can lead to kidney infection (pyelonephritis) and kidney damage. Most kids outgrow the condition. Some might need surgery to correct the reflux.

Some kids with VUR benefit from daily treatment with a small amount of antibiotics, which can also make surgery unnecessary. Kids with VUR should see a pediatric urologist, who can decide if antibiotic treatment is the best option.

In some cases, surgery is needed to correct VUR. The most common procedure is ureteral reimplantation, in which one or both of the ureters are repositioned to correct the backflow of urine from the bladder. This procedure requires only a small incision and, in some children, can be done using robotic-assisted laparoscopy. When surgery is necessary, the success rate is high, but not everyone is a good candidate for it.

Kids may be candidates for ureteral reimplantation if they:

• have an intolerance to antibiotics
• get recurrent infections while on antibiotic treatment
• have severe, or "high-grade," reflux
• are older kids and teens with reflux

An alternative to ureteral reimplantation is endoscopic injection of a material to block the entry of the ureter into the bladder and prevent VUR. In this procedure, a narrow tube called an endoscope is inserted through the urethra into the bladder. The endoscope has a tiny camera at the tip, so the surgeon can guide it to the proper location and inject the material, which helps keep pee from refluxing back into the kidneys. Endoscopic injection is less invasive than surgery, but the results are not as good. A pediatric urologist can help families decide on the best treatment for a child with VUR.

Some kids have recurrent infections that are not caused by anatomical defects or other treatable problems. They might take antibiotics for months or even years to prevent recurrent infections. This treatment is known as continuous antibiotic prophylaxis.

How Can Parents Help?

At home, these things can help prevent recurrent UTIs in kids:

Drinking Fluids
Encourage kids to drink 8–10 glasses of water and other fluids each day. Cranberry juice and cranberry extract are often suggested because they may prevent E. coli from attaching to the walls of the bladder. Always ask your doctor, though, if your child should drink cranberry juice or cranberry extract, because they can affect some medicines.

Good Bathroom Habits
Peeing often and preventing constipation can help to prevent recurrent infections.

No Bubble Baths
Kids should avoid bubble baths and perfumed soaps because they can irritate the urethra.

Frequent Diaper Changes
Kids in diapers should be changed often. If poop stays in the genital area for a long time, it can lead to bacteria moving up the urethra and into the bladder.

Proper Wiping
Girls should wipe from front to back after using the toilet to reduce exposure of the urethra to UTI-causing bacteria in poop.

Cotton Underwear
Breathable cotton underwear is less likely to encourage bacterial growth near the urethra than nylon or other fabrics.

Regular Bathroom Visits
Some kids may not like to use the school bathroom or may become so engrossed in a project that they delay peeing. Kids with UTIs should pee at least every 3 to 4 hours to help flush bacteria from the urinary tract.

When Should I Call the Doctor?

As soon as you think that your child has a UTI, call your doctor. The doctor may recommend another urine test after treatment to be sure that the infection has cleared.

If your child has from recurrent UTIs, consult a pediatric urologist, who can do a thorough evaluation and order tests for urinary system abnormalities. In the meantime, follow your doctor's instructions for treating a UTI.

Looking Ahead

Recent studies have found that women and kids who get recurrent UTIs may lack some types of immunoglobins (a group of proteins that fight infections). Some researchers are optimistic that a vaccine may be developed to help boost production of antibodies that fight UTIs. A promising vaccine that would protect against E. coli (the most common bacterium that causes UTIs) is being tested.