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| Year : 1983 | Volume
: 29
| Issue : 3 | Page : 156-9 |
Management of recurrent urinary tract infections in female children.
Yadav KK, Rao KL
How to cite this article:
Yadav K K, Rao K L. Management of recurrent urinary tract infections in female children. J Postgrad Med 1983;29:156 |
In young children less than 10 years of age, the urinary tract infections (UTI) are more frequent in females than in males. However, the female children are more prone to have pyelonephritis than cystitis. Since the pyelonephritic process gradually destroys the renal tissue, early diagnosis and adequate treatment of UTI is of paramount importance. We report our experience with 25 female children with recurrent UTI and their management with urethral dilatation and long term antibiotic therapy.
Over a period of two and half years, 25 female children with persistent or recurrent UTI, despite repeated antibiotic therapy were referred to the UTI clinic of PGI, Chandigarh. Majority of the children were between 3 and 11 years of age and the youngest was 7 months old. The duration of symptoms varied between 4 and 24 months. There were 2-3 attacks of infection in 14, 4-6 attacks in 6 and multiple in 5 children. All cases received antibacterial drugs prior to referral, with temporary relief. Frequency of micturition and dysuria were the most common symptoms [Table - 1] Urine culture and blood urea were done in all the cases, cystourethrogram in 23, IVP in 22 and dilatation of urethra in all the cases [Table - 2] For culture, midstream urine specimen was obtained after adequate preparation of genitalia. A colony count of 100,000/ml or more was interpreted as significant infection. All the patients received one of the antibacterial drugs (cotrimoxazole, nitrofurantoin, nalidixic acid, gentamicin) depending on the severity of symptoms and the urine culture reports. The antibiotics were given for 2-3 weeks, followed by urethral dilatation. Stenosis of distal urethra was assessed under general anaesthesia using Clutton dilators and dilated upto 18-28 F depending on the age of the child. Cystoscopy in 25 and voiding cystourethrograms were done in 23 cases. After dilatation, antibiotics were continued for 12 weeks. At the end of this 3 months' therapy, the overall assessment based on clinical improvement and urine examination was made in all the cases. The management protocol is given in [Table - 3]
The results of laboratory and radiological investigations are given in [Table - 2] With dilatation of urethra followed by antibiotics for 12 weeks, 19 out of 25 cases (76%) were free of symptoms and the urine was without infection in atleast 2 follow-ups of 6 months' interval. Six of the 25 cases (24%) were re-admitted with second infection and required repeat dilatation and antibiotic therapy. Most of the patients in this group have confessed cessation of treatment after 4-5 weeks of therapy. All these cases who required second dilatation were screened carefully for local infection or any external irritant and we found irregular bowel habits, unhygienic method of cleansing, vaginal infection, constipation, fissure in ano and mild local urethral infection as the basic factors of irritation of the distal urethral ring. Appropriate measures against these ailments and low dose antibacterial drugs for 6 months were successful in eradicating the infection in all these refractory cases, except in an 8 years old child who was irregular with her medications. For patients with vesicoureteral reflux, triple micturition along with dilatation and antibacterial cover helped in 3 out of 5 cases. The remaining 2 underwent antireflux surgery and continuous antibiotic cover for 1 year. At the end of treatment schedule, 24 children were free of symptoms and 3 urine cultures with 1 month interval and without antibiotic cover were negative for sepsis.
Importance of regular follow up needs to be stressed with the parents. The patients were advised to attend follow up clinic every 6 weeks for atleast 1 year, unless early visit is required due to fresh attack of urinary tract infection. Those children who were free of infection for over 1 year with low dose antibiotic therapy, were slowly weaned off the drugs and all except 1 patient were infection free.
Though the symptomatology of recurrent LM on presentation was obstructive in nature in most of the cases, yet only 4 children had definite stenosis of the distal urethral ring. The association of urethral stenosis and UTI is a well established fact. However, the reason for the presence of obstructive urinary symptomatology with normal calibre of distal urethral ring was not clearly mentioned in the literature.[2] Tanagho et al[3] reported their detailed physiological study of the female children with recurrent UTI, where urinary infection could not be controlled with antibacterial therapy and in those cases, stenosis of the distal urethral ring was considered to be the basic obstructive mechanism. According to this report, the actual site of resistance to voiding was present at the level of the striated external sphincter around the mid-urethra, and this resistance was encountered both during voiding and resting phase at the same site. Since the sensory supply of the distal urethral segment and the external meatus is via the branches of the pudendal nerve, it appears that the removal of stimuli to the distal urethral ring due to infection or local irritation will return the voiding dynamics to normal.
Although 76% of the cases showed excellent result following a single dilatation of the urethra, the continuous cover with antibiotic therapy for a longer period was not accepted easily by the parents. As a result, 24% of the cases required a second dilatation within 5 months. All the cases who developed recurrent infection were found to have ailments which cause perineal irritation and the corrective measures were very helpful in controlling the UTI, along with urethral dilatation and long term antibiotic therapy. Association of extra urinary ailments increases the duration of antibiotic therapy. Our experience is similar to others[1], [4] in that the calibre of the urethral ring is not the determining factor either in the severity of symptoms or the cure rate. However, in all the cases stimulus to the distal urethral ring either due to infection or local irritation, if removed completely for sufficient time (which we find variable), the voiding dynamics return to normal.
| 1. | Graham, J. B., King, L. R., Kropp, K. A. and Uehling, D.: The significance of distal urethral narrowing in young girls J. Urol., 97: 1045-1049, 1967.  |
| 2. | Lyon, R. P. and Smith, D. R.: Distal urethral stenosis. J. Urol., 89: 414-421, 1953. |
| 3. | Tanagho, E. A., Miller, E. R., Lyon, R. P. and Fisher, R.: Spastic striated external sphincter and urinary tract infection in girls. Brit. J. Urol., 43: 69-82, 1971. |
| 4. | Weiss, J. M., Dykhuizen, R. F., Sargent, C. R. and Tandy, R. W. Jr.: Urinary tract infection in girls. A computerised analysts of urethral stenosis. J. Urol., 100: 513-519, 1968. |
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