2025 – PAGE 381 – NEPHROLOGY
URETEROCELE
Ureterocele is the most common cause of urinary retention in girls. It may be associated with abdominal pain, dysuria, and/or hematuria (could sound similar to a UTI!). Look for a filling defect on the IV PYELOGRAM (IVP). The filling defect is where the mass is located.
IMAGE: www.pbrlinks.com/URETEROCELE1
IMAGE: www.pbrlinks.com/URETEROCELE2
IMAGE: www.pbrlinks.com/URETEROCELE3
INFECTIONS
URINARY TRACT INFECTION (UTI or PYELONEPHRITIS)
If a urinary tract infection (UTI or pyelonephritis) is diagnosed and the urinalysis shows POSITIVE NITRITES, this is virtually diagnostic of a GRAM-NEGATIVE organism (E. coli, Klebsiella pneumoniae, and Proteus). If nitrites are negative, the UTI could be due to a gram-positive organism (especially Enterococcus or Staph. saprophyticus). For most UTIs, give outpatient therapy. If the patient is not septic, has a low likelihood of renal disease (no fever or back pain) and can tolerate orals, give a 1st generation cephalosporin (cephalexin) for 5 days. If there is concern for possible renal disease (fever with or without back pain), give a 3rd generation cephalosporin (cefixime or cefdinir) for 10 days. If there is a severe allergy to penicillin/cephalosporins then treat with trimethoprim-sulfamethoxazole. If allergic to sulfa medications, then treat with ciprofloxacin. Early treatment is key to prevent renal damage. If the patient has nausea and vomiting from pyelonephritis, they cannot tolerate outpatient therapy and should be hospitalized. Inpatient treatment should be with an IV cephalosporin (ceftriaxone, cefepime or cefotaxime). Ampicillin and gentamicin as a combination may also be acceptable.
- FIRST FEBRILE UTI (2-24 months of age): Treat with antibiotics and obtain renal and bladder ultrasound. A renal ultrasound will look for structural problems (kidneys, ureters, bladder). Since there is still ongoing debate between pediatric urologists, as of this time, it is not recommended to routinely obtain a VCUG after the first febrile UTI.
- RECURRENT FEBRILE URINARY TRACT INFECTIONS: Further evaluation is needed, including VCUG if not previously done. A VCUG will look for ureteropelvic junction obstruction (UPJ obstruction), vesicoureteral reflux (VUR), and posterior urethral valves (PUV). Wait to order the VCUG until at least a week after UTI resolution. Routine antibiotic prophylaxis is no longer recommended. Rather, parents should be instructed to seek medical attention for future febrile episodes within 48 hours so that a prompt workup can be done for possible UTI.PEARL: Febrile UTI in a young child is associated with a HIGH rate of vesicoureteral reflux (VUR).PEARL: Cephalosporins inadequately treat Enterococcus UTIs. Add on ampicillin or amoxicillin if there is an increased chance of an Enterococcal infection due to a urinary tract anatomic abnormality, presence of a urinary catheter, or history of recent urinary tract procedure.