The Significance of Urinary Tract Infection in Girls in the Absence of Vesicoureteral Reflux

Vol. 103, Mara

THE JOURNAL OF UROLOGY

Copyright © 1970 by The Williams & Wilkins Co.

Printed in U.S.A.

THE SIGNIFICANCE OF URINARY TRACT INFECTION l':'-J GIRLS IN THE ABSENCE OF VESICOURETERAL REFLUX SAUL J. KLEIN, NL RICHARD CARLIN

AND

WILLIAM T. BOWLES

From. the Department of Surgery, Division of Urology, Washington University School of il!Jeclicine, St. Louis, iVlissO'l.tri

:Many children with urinary tract infection do riot suffer permanent injury. However, some children have recurrent infections culminating in kidney damage and, less frequently, chronic renal impairment. We thought it would be helpful to know if one could predict whether a child with an infection will have continuing urinary tract complications or a favorable long-term prognosis. MATERIALS

Our report is based on an analysis of case records of girls admitted to the St. Louis Children's Hospital for urinary tract infections between 1959 and 1964 and the records of their subsequent followup examinations. All children were the private patients of one of the authors (MRC). In this 5-year period 58 patients satisfied our criteria for the study group· 1) recurrent urinary tract infection, 2) absence of vesicoureteral reflux and 3) normal excretory urograms (IVPs). During 1968 an effort was made to collect followup information. Parents were contacted by letter and telephone. In many cases the girls were re-examined in the office. Sufficient information for this study was obtained in 48 cases. HOSPITAL STUDY

The girls ranged in age from 6 months to 11 years when first examined (average 5½ years and median 6 years). The followup period ranged from 4 to 9 years with an average of 6 years. Each child had had at least 2 and as many as 15 episodes of urinary tract infection before hospitalization. There was a time lapse of 3 months to 7 years from the first known episode of infection to the initiation of urological evalimtion. The patient was considered to have had a urinary tract infection if there was a history of irritative voiding symptoms or fever with pyuria or bacteriuria. All but 1 patient had symptomatic infections with either dysuria, frequency, incontinence or Accepted for publication April 2, 1969.

fever. On admission pyuria was present in 30 patients (62 per cent) and bacteriuria in 18 per cent), Cultures were less commonly done 5 to 10 years ago particularly in the referring physician's office where a diagnosis of urinary tract infection wa3 usually made. There were 13 patients (27 per cent) diagnosed as having acute pyelonephritis because in addition to an abnorrnaE sediment they had fever, chills or prostration. Most patients, when admitted to the hospital, were asymptomatic or receiving antibiotics so that inpatient urinalysis and urine cultures were not usually abnormal. All patients had a cystogram and an IVP, In every case cystograms showed no vesicoureteral reflux. Some cystographic examinations showed bladder trabeculation and others showed abnormal voiding urethrograms. The IVPs were all considered normal. All patients underwent cystoscopy, urethro .. scopy and urethral calibration under anesthesia. Based on the cystoscopic findings the anatomical diagnoses included urethritis, 17 (36 per cystitis, 10 (20 per cent); urethral stenosis, 10 (20 per cent); bladder neck obstruction, 4 (8 per cent); meatal stenosis, 3 (7 per cent) and foreign body in the vagina, 1 (2 per cent). Antibiotics were always prescribed for 2 weeks to several months following hospitalization. Fourteen patients had dilation of the urethrn as part of the initial treatment: fulguration of the urethra was performed in 13 patients and l patient had a transurethral resection of the bladder neck. RESULTS

Following the single urological evaluation 32 patients (67 per cent) bave not had another known urinary tract infection . Nine patients (19 per cent) had only 1 documented infection. Seven patients (14 per cent) had more than l infection. Of the 16 patients who did have recurrence of infection 14 did so in the first 2 years after urological diagnostic studies and 10 have not ha.cl another infection since 345

346

KLEIN, CARLIN AND BOWLES

Six of the 48 children (12.5 per cent) continue IVPs were present in 25 per cent of the cases at to have urinary· tract infections. Four have had followup examination. Again there were no earlier infections in the past year and the other 2 have x-rays for comparison. Positive cultures or pyuria required antibiotics for almost 2 years in order to were present in 15 per cent of the cases. These keep them free of infection. ·The latter 2 girls authors concluded that all cases of urinary tract with 6 recurrence(> each have .had ,repeat IVPs infection in childhood should have a urographic and cystograms which show normal upper .tracts study as part of followup. and no vesicoureteral reflux. One child has had · McCaulay studied both boys and girls after h,~r third recurrence and followup IVP and cysto- their infection and found that 5 died, 13 had gram are unchanged. There are 3 children who either recurrent or persistent signs of infection had relapses in 1967, 6, 5 and 3 years after initial and 13 were normal.3 There was no mention of the evaluatio;n and repeat IVPs have not yet been severity of the urinary tract abnormalities of each obtained. group before followup. Steele and associates reported on re-examina.Forty-two patients have not shown continuing infection. Of these 24 have had recent negative tion of children of both sexes who had had urinary clean-void urine cultures. There were 13 patients tract infections an average of 16 years previously. 4 with clinical pyelo1:i-ephritis and only 1 (7 per The followup results were not encouraging: 18 per cent died, 22 per cent were living with percent) is. in the .group with recurring infection. sisting infection and 8 per cent had progressive DISCUSSION renal insufficiency. The prognosis was unusually Previous reports on followup of children who poor because many children had marked obhave had urinary tract infection have stressed structive disease, chronic pyelonephritis and imthe anatomical abnormalities found when IVPs paired renal function initially. These authors were taken several years later. In many cases one thought that the patients with no radiographic cannot be sure that the abnormality found was changes of the kidney when first examined apalways present or was the end result of recurring peared to do better than those with changes of infection. The inclusion of such children with pyelonephritis. They could not find a correlation significant urological disease in a followup group between the severity of the clinical infection and made the over-all prognosis for all children with subsequent urinary tract infections or advancing renal disease. The presence or absence of reflux infection less favorable. Wharton and Gray reported that 17 of 30 girls was not determined. A more recent evaluation of 350 children fol(57 per cent) who had acute pyelitis as children demonstrated abnormalities of the urinary tract lowing urinary tract infection showed a 41 per when examined an average of 13 years later. 1 cent recurrence rate. 5 The relapse rate was highest Some of these abnormalities were accompanied by during the first 18 months post-treatment. Chilsymptoms of back pain and enuresis. Other ab- dren with no urological complication requiring an normalities noted were hydronephrosis and upper operation had a 20 per cent relapse rate. We chose to examine the significance of the tract dilatation. There were no earlier films available to determine whether the upper tract findings of both normal IVPs and the absence of damage was pre-existent or was caused by ureterovesical reflux on the natural history of infection. These authors also found that while urinary tract infections in otherwise healthy girls. half of the children had positive urine cultures A duplicated collecting system was not considered at followup most were asymptomatic. While this abnormal. None of the children had thinning of finding differs from our observation, it is difficult the cortex, calyceal clubbing, ureteral dilatation to know if the organisms isolated were pathogens or calculi. The determination of reflux was considered imand if the colony counts were significant. Woodruff and Everett studied 76 girls with pre3 McCaulay, D. and Sutton, R. N. P.: The progvious infections 5 to 23 years later. 2 Abnormal nosis of urinary infections in childhood. Lancet, Wharton, L. R., Gray, L.A. and Guild, H. G.: The late effects of acute pyelitis in girls. J.A.M.A., 1

109: 1597, 1937. 2 Woodruff, J. D. and Everett, H. S.: Prognosis

in childhood urinary tract infections in girls. (Holmes lecture). Amer. J. Obstet. Gynec., 68:

798, 1954.

2: 1318, 1957.

4 Steele, R. E., Jr., Leadbetter, G. W., Jr. and Crawford, J. D.: Prognosis of childhood urinary tract infections. The current status of patients hospitalized between 1940 and 1950. New Engl. J. Med., 269: 883, 1963. 5 Stansfeld, J. M.: Relapses of urinary-tract infections in children. Brit. Med. J., 1: 635, 1966.

URINARY TRACT INFECTION IN GIRLS WITHOUT REFLUX

portant as its appearance represents a definite functional abnormality and it may contribute to upper tract deterioration even without the presence of infection. 6 • 7 ··whereas reflux can be objectively and readily diagnosed the other findings on a voiding cystourethrogram, such as bladder neck obstruction, urethral stenosis and meatal ~tenosis, are difficult to interpret in female sub'vVe believe that the x-l'ay diagnosis of urethral disease was fraught with too much uncertainty to warrant its inclusion as a prognostic variable. The same is to be said of the endoscopic diag-· noses of these conditions. Although the cystoscopic observation of trabeculation was made and the amount of residual urine was noted for each patient in the diagnostic study these findings were not used to evaluate the ability to predict which patients would more likely have future urinary tract infections. Although the relapse rate of infection in our study group was 33 per cent none of the children have had progressive renal damage from infection. Cystoscopy may have had some therapeutic 6 Hinman, F., Jr. and Hutch, .J. A.: Atrophic pyelonephritis from ureteral reflux without obstructive signs ("refilL'{ pyelonephritis"). J. Urol., 87: 230, 1962. 7 Hutch, J. A. and Tanagho, E. A.: Etiology of non-occlusive ureteral dilatation. J" Urol.. 93: 177,

1965"

,

,

347

benefit since 67 per cent of the children had no further infection after this procedure. \Ve do not wish to minimize the potential seriousness of urinary tract infection in children, Our findings emphasize the need for urological infec,. evaluation of children who ham had t.ion, not only to find an underlying cause and assist in its treatment but to predict the future clinical course of that child. \Nithit1 the strict limit~ set by this short-term study,yefound a 12.5 per cent infection rate but no child has had anatomical renal damage secomfary to infection. SU'\IMARY

A re-evaluation of 48 girls with urinary tract infection was clone. Normal IVPs and no vesicoureteral reflux were noted. The primary treatment was antibiotics alt.bough other forms of therapy were used in some cases. Two-thirds of the patients had no further infection aft.er diagnostic studies and 87 ,5 per cent have not had a recurrence in at least 2 years. Recent urine cultures obtained in half of this asymptomatic group have been negative, Of the 6 children who are having recurring infections or who need antibiotics to stay free of infection, 3 have had repeat IVPs and cystograms and these are still normal. Therefore, we conclude that girls who have had urinary tract infection have a favorable prognosis if they have no reflux and normal IVPs on initial urologic: examination,