Urinary tract infections: Pros and cons of testing

My three year old has her second urinary infection since January, and my pediatrician wants to send her for a renal ultrasound and a VCUG. I'm not too worried about the ultrasound, but I'm worried about mental and physical side effects of the VCUG which I understand involves catheterization. I'd like your opinion of the pros and cons of these tests.

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Robert Steele

Robert W. Steele, MD, is a board certified pediatrician at St. John's Regional Health Center in Springfield, MO. He graduated from medical... Read more

Your question has been the hot topic of debate among doctors for the past several years, so already you can tell there may not be a right or wrong answer to your question. However, you phrase your question in great way because the pros and cons are exactly what you and your doctor should discuss together when considering this issue. But to understand the pros and cons, it is good to get a grasp of a little background about how this controversy came into being.

It was recognized for many years that there are certain people who have kidneys that begin to fail at an early age in life such as the 30's and 40's. In looking for reasons for this kidney failure, researchers began to question what role urinary tract infections had in causing this eventual deterioration of the kidney. As technology became better, it was soon realized that some children develop what is called reflux which I have discussed previously. This reflux occurs when the bladder sends urine back up toward the kidney instead of outside the body, and it is felt to be a risk factor of developing kidney infections. Therefore, many felt that it might be the combination of reflux and urinary tract infections (UTI) that caused this kidney damage. Well, radiology technology has gotten even better, and we can now see the actual scarring of the kidney that occurs with reflux and urinary tract infections that involve the kidney.

But here is where the controversy comes in. Although we know that reflux can increase the risk of urinary tract infections, there are many children who have mild to moderate reflux that never have a UTI. Although we know UTI's that involve the kidneys (called pyelonephritis) can cause scarring, we currently have no scientific evidence that this scarring causes any future problems. The whole purpose of this testing is to prevent kidney failure later in life. But some argue there is not enough evidence that testing actually correctly identifies those children at risk for this. Nonetheless, there certainly are children who have severe reflux or urinary tract abnormalities which need treatment who are identified with these tests. It would be nice to be able to predict which children with UTI's actually have one of these abnormalities so they alone would be tested, however, this is currently impossible.

There are some physicians who advocate that these tests be done in any child who has their first UTI before the age of 5 years. Then there are others who feel these tests are needless until the female child has had at least  2 UTI's. Since it is quite unusual for a male to get a UTI, most pediatricians are quick to order these tests for boys. However, UTI's can be rather common in girls, so many pediatricians choose to only test those who may be at higher risk for actually having a structural abnormality and/or reflux. These girls would include those who have had multiple infections, infections with unusual bacteria, or other abnormalities on physical exam. So now let me outline the pros and cons of the kidney ultrasound and VCUG (Voiding Cystourethrogram):

Kidney Ultrasound

Purpose: To look at the structure of the kidneys to see if there is any abnormality that would predispose the child to UTI's. Note it does not look for reflux, but rather it shows whether or not all the parts are connected correctly

Pros: It is non-invasive. The child does not need to be sedated.

Cons: The quality of the ultrasound is dependent upon both the ultrasound technician and the radiologist reading the ultrasound. If either of these people is not well experienced with children, the reading may not be as accurate.

VCUG

Purpose: To look for urinary reflux. It also allows the doctor to see some of the structure of bladder.

Pros: It is usually good at picking up whether reflux is present or not. It can also look at the valves of the bladder which cannot be easily visualized by ultrasound.

Cons: It is invasive in that the child must undergo catheterization. If the test is done too early after the UTI, the test could show reflux caused by the infection that would normally go away after treatment.

Laura, as with any invasive procedure, I suggest you prepare your daughter by talking about it with her, letting her know there will be some pain but that you will be there with her, and then having a game plan while the procedure is taking place such as reading stories. If the hospital has a child life specialist, I would strongly encourage you to contact her as she could be an invaluable resource in preparing your daughter for the VCUG.

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