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Subject: Re: Deciding on VCUG for 5 year old
Forum: The Urology Forum
Hello,
My 5 year old daughter, (6 in May) has had a history of bladder infections within the past year and a half. She has been under the care of a pediatrician. Her first two infections were uncultured but did show white blood cells and blood. These were discovered at a walk-in emerg. setting and uncultured. They were four months apart. With a pediatriac follow up visit a renal ultrasound and monthly cultures were done for 6 months. ALL were negative. At that point the pediatrician chose not to do the more invasive VCUG. Since then, she has had three more infections, only the most recent one was considered a UTI with the presence of e. coli. With this first positive a VCUG is now scheduled.
I am questioning if the VCUG is necessary at this point because of the following: The last postive UTI was also accompanied with an flu/diarhea and ear infection, and more importantly my daughter wets nightly and has never had a dry night. I have read that this can predispose recurrent infections. (Simply being in a wet "pull-up" every night) My husband suffered bedwetting until 11 years old. Also there is a history of recurrent UTI's on my side of the family.
I'm wondering if DDAPV usage for 6 months might help the bedwetting and inturn eliminate the infections. I am very concerned and understand the risks that reflux can cause but want to be cautious before doing this more invasive procedure. I have read conflicting articles of when VCUG is recommended.
Thank you for your response,
JULIE
Dear Julie,
Reflux is more common in girls and is usually present from birth. It can occur on one or both sides and can predispose to infections. Reflux is usually discovered because of a urinary tract infection although sometimes it is discovered after an enlarged renal pelvis is seen on an ultrasound. The routine tests for a documented UTI in a child is a VCUG and ultrasound(renal/bladder). This test (VCUG) can be done with contrast or a radiotracer in the nuclear medicine department. Many urologists prefer the contrast study so that they can grade the reflux. If you decide to have this test done, be sure that the voiding phase is included. Sometimes radiologists are unable to get the child to void and stop the study. Sometimes reflux does not occur until voiding begins. If you stopped the study before voiding, you might miss the reflux.
You are well informed and understand that this test is invasive. It involves placement of a catheter in the bladder which is difficult in children particularly around your daughters age. Reflux is diagnosed if the contrast or radiotracer is forced backwards into the ureter towards the kidney in a retrograde fashion. This reflux of urine, is caused by a poor valve at the junction of the bladder and ureter.
You may believe that this infection is a result of your daughters recent flu/diarrhea, but with the number of potential infections and a documented infection, I think it would be a good idea to find out for sure. If you do decide to put off the study, make sure that any further episode of fever or symptoms(frequency, urgency) you get a catheterized specimen of urine for evaluation. However, if any of these prior undocumented infections was accompanied by a high fever(>102) I would strongly encourage you to get the study. A high fever would indicate a possible kidney infection and probable reflux.
The most important issue with children with reflux is preservation of the renal function and allowing for normal and complete growth of both kidneys. This means avoiding infections of the kidneys to prevent harmful scarring. Sometimes patients are placed on long-term prophylactic antibiotic therapy. These regimens are usually safe as long they are tolerated well by the child. If your child were managed conservatively(medically) periodic follow-up studies must be done to ensure normal scar free growth.
Also a physical exam sure be performed an special inclusion of height and weight parameters and blood pressure measurements. Laboratory studies should include a urinalysis and urine culture at each visit In terms of radiology tests, a IVP or ultrasound should be obtained every 18-24 months. After the initial VCUG has been performed to establish to current grade, a follow-up study should be performed to establish an interval relationship or resolution.
To address the incontinence issue, enuresis, I dont think that DDAVP would alter your daughters chance of infection. It may help with her bed-wetting, but vaginal colonization is usually to cause of infection and some people are genetically more likely to get a UTI.
Overall, I would talk to your doctor about your options, however, with the situation you have presented, most urologists would recommend the VCUG.
This information is provided for general medical educational purposes only. Please consult your physician for diagnostic and treatment options pertaining to your specific medical condition. More individualized care is available at the Henry Ford Hospital and its satellites (1 800 653-6568).
Sincerely,
HFHS M.D.-AK
*keyword:Reflux
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