Is VCUG Still Indicated Following the First Episode of Urinary Tract Infection in Boys?

doi:10.1016/j.urology.2012.03.073

Urology

Volume 80, Issue 6, December 2012, Pages 1351-1356

https://doi.org/10.1016/j.urology.2012.03.073 Get rights and content

Objectives

To determine if voiding cystourethrogram (VCUG) following first episode of urinary tract infection (UTI) offers any incremental diagnostic advantage in boys if a comprehensive renal and bladder ultrasonogram (RBUS) revealed no abnormalities.

Methods

All boys less than 10 years of age whose first evaluation for UTI included RBUS and VCUG were retrospectively studied over a 10-year period. Those with a disorder of the urinary tract known before imaging were excluded. RBUS and VCUG results were analyzed.

Results

Of the 77 who met the inclusion criteria, 58 (77%) were <1 year old. 45 (58%) boys had normal RBUS and VCUG. In 16 (21%) both studies were abnormal: 15 had vesicoureteral reflux (VUR) and one had posterior urethral valves. The remaining 16 (21%) had one abnormal study: 10 had pelvicaliectasis on RBUS without VUR; 6 had normal RBUS with VUR. No urethral abnormality was diagnosed on VCUG when RBUS was normal. Of the six who had VUR and normal RBUS, the one who required surgical intervention had recurrent febrile UTI.

Conclusions

If a well-performed RBUS is normal in a boy with first UTI, the likelihood of a significant finding in VCUG is low. A VCUG is likewise of no apparent screening benefit for obstructive uropathy. With the uncertainties surrounding the benefit of chemoprophylaxis, omitting a VCUG when a RBUS is normal in boys with a first UTI avoids the morbidity without missing important pathologies or altering evolving management protocols.

Section snippets

Material and Methods

With the approval of our Institutional Review Board, we retrospectively reviewed the records of all boys younger than 10 years of age who underwent RBUS and VCUG at our institution, after the first episode of symptomatic UTI. This cohort includes predominantly boys who were referred by pediatricians after treatment for imaging at our institution. Only an opinion was sought for most of these, by the treating pediatrician, and some were evaluated by our division. All boys who underwent RBUS and

Results

Of the 88 boys who underwent both RBUS and VCUG after the first episode of UTI, 77 satisfied the inclusion criteria. Of the 11 who were excluded, 6 had known pathology before imaging, 2 had antenatal hydronephrosis, and 3 had neurovesical dysfunction. Fifty-eight (77%) were younger than 1 year old. In all, RBUS was normal in 51 (Fig. 1). In 45 boys (58%) both RBUS and VCUG were normal. Of the remaining 32, both studies were abnormal in 16 (21%): All of these had varying degrees of upper tract

Comment

Although the AAP guidelines for febrile UTIs in 1999 for children from 2 months to 2 years of age recommended RBUS and either VCUG or radionuclide cystogram as early as possible to rule out VUR and other congenital urologic anomalies,³ the current guidelines do not advocate VCUG in all children.⁴ This is consequent to the body of evidence questioning the significance of chemoprophylaxis after a diagnosis of VUR in all children. In our study population, of the 77 boys who underwent both RBUS and

Conclusions

With the current understanding of VUR and the less convincing role of intervention in low-grade VUR, RBUS alone is sufficient in most boys with a first episode of febrile UTI. Investigation related-morbidity is avoided without an added risk of missing clinically significant diagnosis. Performing VCUG in those with suspicious findings on RBUS or recurrent UTI will increase the yield of lesions that warrant intervention and minimize the anxiety related to diagnosing low-grade VUR.

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Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study
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Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars?A randomized, controlled trial
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Imaging studies after a first febrile urinary tract infection in young children
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Renal function 16 to 26 years after the first urinary tract infection in childhood

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Cited by (10)

Adherence to the 2011 American Academy of Pediatrics Urinary Tract Infection Guidelines for Voiding Cystourethrogram Ordering by Clinician Specialty
2019, Urology
To evaluate rates of guideline adherence and associations with voiding cystourethrogram result. The American Academy of Pediatrics guidelines recommend voiding cystourethrogram after abnormal renal ultrasound or 2 febrile urinary tract infections. It is unclear whether guideline adherence increases vesicoureteral reflux detection. Additionally, guidelines targeting children 2-24 months are often applied to other ages.
Children undergoing voiding cystourethrogram from January 2012 to December 2013 at 1 institution were retrospectively reviewed. Children with known genitourinary abnormalities were excluded. The primary outcome was guideline adherence. Univariate and multivariate analyses were performed. Subgroup analysis of children 2-24 months was completed.
Voiding cystourethrograms from 365 children were included in the primary analysis, including 187 (51.2%) aged 2-24 months. Overall, 60.3% of voiding cystourethrograms were ordered in accordance with the guidelines. Urologists/nephrologists were more likely to adhere to ordering guidelines than pediatricians/others (76.4% vs 51.7%, odds ratio 3.0 [1.9-4.9], P <.001). Subgroup analysis in children 2-24 months revealed similar findings (76.4% vs 51.5%, odds ratio 3.0 [1.5-6.2], P = .002). Voiding cystourethrograms were abnormal in 31.8% overall and 26.2% aged 2-24 months. Guideline adherence was associated with increased likelihood of abnormal voiding cystourethrogram among all children (P = .02), but not among children 2-24 months (P = .95). Older age, white race, and guideline adherence remained significantly associated with abnormal voiding cystourethrogram in a multiple logistic regression model.
Guideline adherence was more likely among urologists/nephrologists than pediatricians/others and was not associated with abnormal voiding cystourethrogram among children 2-24 months. Multicenter evaluation is necessary to determine if ordering recommendations should be revised.
Probabilities of Dilating Vesicoureteral Reflux in Children with First Time Simple Febrile Urinary Tract Infection, and Normal Renal and Bladder Ultrasound
2016, Journal of Urology
Citation Excerpt :
Conversely VUR is more prevalent in girls if the RBUS is normal.7,8 Moreover, the chance of detecting significant findings on VCUG is low in boys 1 to 10 years old with normal RBUS.25 In our study gender was not a risk factor for dilating VUR.
We evaluated risk factors and assessed predicted probabilities for grade III or higher vesicoureteral reflux (dilating reflux) in children with a first simple febrile urinary tract infection and normal renal and bladder ultrasound.
Data for 167 children 2 to 72 months old with a first febrile urinary tract infection and normal ultrasound were compared between those who had dilating vesicoureteral reflux (12 patients, 7.2%) and those who did not. Exclusion criteria consisted of history of prenatal hydronephrosis or familial reflux and complicated urinary tract infection. The logistic regression model was used to identify independent variables associated with dilating reflux. Predicted probabilities for dilating reflux were assessed.
Patient age and prevalence of nonEscherichia coli bacteria were greater in children who had dilating reflux compared to those who did not (p = 0.02 and p = 0.004, respectively). Gender distribution was similar between the 2 groups (p = 0.08). In multivariate analysis older age and nonE. coli bacteria independently predicted dilating reflux, with odds ratios of 1.04 (95% CI 1.01–1.07, p = 0.02) and 3.76 (95% CI 1.05–13.39, p = 0.04), respectively. The impact of nonE. coli bacteria on predicted probabilities of dilating reflux increased with patient age.
We support the concept of selective voiding cystourethrogram in children with a first simple febrile urinary tract infection and normal ultrasound. Voiding cystourethrogram should be considered in children with late onset urinary tract infection due to nonE. coli bacteria since they are at risk for dilating reflux even if the ultrasound is normal.
Urinary tract infection in pediatrics: an overview
2020, Jornal de Pediatria
Citation Excerpt :
None of these recent guidelines recommend routine VCUG or DMSA scans, but they recommend further evaluation if the ultrasound is abnormal, if the child is critically ill and fails to respond promptly to antibiotics, and in case of recurrent infections. Some studies have evaluated the impact of fewer investigations and concluded that the recent guidelines are safe to follow.88–90 On the other hand, other authors consider that potentially important abnormalities will be missed if the newer guidelines are followed.91
This review aimed to provide a critical overview on the pathogenesis, clinical findings, diagnosis, imaging investigation, treatment, chemoprophylaxis, and complications of urinary tract infection in pediatric patients.
Data were obtained independently by two authors, who carried out a comprehensive and non-systematic search in public databases.
Urinary tract infection is the most common bacterial infection in children. Urinary tract infection in pediatric patients can be the early clinical manifestation of congenital anomalies of the kidney and urinary tract (CAKUT) or be related to bladder dysfunctions. E. coli is responsible for 80–90% of community-acquired acute pyelonephritis episodes, especially in children. Bacterial virulence factors and the innate host immune systems may contribute to the occurrence and severity of urinary tract infection. The clinical presentation of urinary tract infections in children is highly heterogeneous, with symptoms that can be quite obscure. Urine culture is still the gold standard for diagnosing urinary tract infection and methods of urine collection in individual centers should be determined based on the accuracy of voided specimens. The debate on the ideal imaging protocol is still ongoing and there is tendency of less use of prophylaxis. Alternative measures and management of risk factors for recurrent urinary tract infection should be emphasized. However, in selected patients, prophylaxis can protect from recurrent urinary tract infection and long-term consequences. According to population-based studies, hypertension and chronic kidney disease are rarely associated with urinary tract infection.
Many aspects regarding urinary tract infection in children are still matters of debate, especially imaging investigation and indication of antibiotic prophylaxis. Further longitudinal studies are needed to establish tailored approach of urinary tract infection in childhood.
Esta revisão teve como objetivo fornecer uma visão crítica da patogênese, achados clínicos, diagnóstico, investigação por imagem, tratamento, quimioprofilaxia e complicações da infecção do trato urinário em pacientes pediátricos.
Os dados foram obtidos de forma independente por dois autores que fizeram uma pesquisa abrangente e não sistemática em bancos de dados públicos.
A infecção do trato urinário é a infecção bacteriana mais comum em crianças. Em pacientes pediátricos, pode ser a manifestação clínica precoce de anomalias congênitas do rim e trato urinário (CAKUT) ou estar relacionada a disfunções da bexiga. A E. coli é responsável por 80–90% dos episódios agudos de pielonefrite adquirida na comunidade, principalmente em crianças. Os fatores de virulência bacteriana e o sistema imunológico inato do hospedeiro podem contribuir para a ocorrência e gravidade da infecção do trato urinário. A apresentação clínica de infecções do trato urinário em crianças é altamente heterogênea, com sintomas que podem ser bastante obscuros. A cultura de urina ainda é o padrão-ouro para o diagnóstico de infecção do trato urinário e os métodos de coleta de urina em centros individuais devem ser determinados com base na precisão das amostras coletadas. O debate sobre o protocolo de imagem ideal ainda está em andamento e há uma tendência a um menor uso da profilaxia. Medidas opcionais e o manejo dos fatores de risco para infecção do trato urinário recorrente devem ser enfatizados. Entretanto, em pacientes selecionados, a profilaxia pode proteger contra infecção do trato urinário recorrente e consequências em longo prazo. Segundo estudos populacionais, hipertensão e doença renal crônica raramente são associadas à infecção do trato urinário.
Muitos aspectos relacionados à infecção do trato urinário em crianças ainda são motivo de debate, principalmente a investigação por imagem e a indicação de profilaxia com antibióticos. Estudos longitudinais adicionais são necessários para estabelecer uma abordagem personalizada da infecção do trato urinário na população pediátrica.
Conflicting views of physicians and surgeons concerning pediatric urinary tract infection: a comparative review
2023, Pediatric Radiology
Management of Vesicoureteral Reflux: What Have We Learned Over the Last 20 Years?
2021, Frontiers in Pediatrics
Urinary tract infection
2016, Clinical Pediatric Nephrology: Third Edition

View all citing articles on Scopus

: Financial Disclosure: The authors declare that they have no relevant financial interests.

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Pediatric UrologyIs VCUG Still Indicated Following the First Episode of Urinary Tract Infection in Boys?

Objectives

Methods

Results

Conclusions

Section snippets

Material and Methods

Results

Comment

Conclusions

Pediatr Clin North Am

J Urol

J Urol

J Urol

A synopsis of the American Academy of Pediatrics' practice parameter on the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children

Pediatr Rev

Urinary tract infection: Clinical Practice guideline for the diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months

Pediatrics

Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study

Pediatrics

Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars?A randomized, controlled trial

Pediatrics

Primary vesicoureteric reflux as a predictor of renal damage in children hospitalized with urinary tract infection: a systematic review and meta-analysis

J Am Soc Nephrol

Imaging studies after a first febrile urinary tract infection in young children

N Engl J Med

Renal function 16 to 26 years after the first urinary tract infection in childhood

Arch Pediatr Adolesc Med

Pediatric Urology
Is VCUG Still Indicated Following the First Episode of Urinary Tract Infection in Boys?