Pediatric Primary Care Case Studies (107 page)

Zamon, E. L., & Kenny, D. J. (2001). Replantation of avulsed primary incisors: a risk-benefit assessment.
Journal of the Canadian Dental Association, 67
, 386.

Chapter 27

The Preschooler with Urinary Urgency and Urinary Incontinence

Shelly J. King

Children may not present with the typical complaints for a urinary tract infection (UTI), making them a challenge to diagnose and treat. In this case study the child has no complaints, but the parents state the child has urinary urgency and incontinence. As you further investigate, you find the child has infrequent urination and hard stools. She also has a prior visit to the emergency room for similar symptoms and fever.

A UTI is a bacterial infection of the kidneys, bladder, or a combination of both. It is a common cause of febrile illness in children. It can be challenging to diagnose because young children cannot communicate symptoms well. Prompt diagnosis and treatment are essential to minimize acute morbidity and decrease the risk of progressive renal dysfunction. The origin of a urinary tract infection is often unclear. Detailed history, complete data collection, and a physical examination are necessary to provide an individualized plan of care.

Educational Objectives

1.   Apply the guidelines for urinary tract infection management.

2.   Determine appropriate interview questions for gathering pertinent data.

3.   Discuss variables affecting management, including age, sex, presentation of illness, compliance, and cultural and socioeconomic factors.

4.   Identify appropriate testing.

   Case Presentation and Discussion

Ashley Jones is a 4-year-old white female who presents in the pediatric clinic for complaints of urinary urgency and foul-smelling urine. Mom describes symptoms of rushing to the bathroom and minor urine leakage during the day over the last 48 hours. She also wet the bed the last two nights. She does not complain of pain with urination and there has been no fever.

Mom reports her concern regarding multiple urinary tract infections over the last year. One infection was associated with fever, flank pain, and vomiting. Mom is very frustrated that this continues to be a problem.

What aspects of the physical examination will be most important?

Physical Examination

Upon physical examination, you find Ashley has no specific abnormalities. Her abdomen is soft and nontender; there is no evidence of a mass. Stool is palpable in the right lower quadrant. She denies costal-vertebral angle (CVA) tenderness. You palpate her lower spine and it is normal. There is no visual evidence of any abnormality, no sacral dimple, discolorations, asymmetry, or hair patch. Her feet are not high-arched and her toes are straight. She has no complaints of back pain, lower extremity pain, or weakness. She has full range of motion and ambulates with a normal gait. The external genitalia yield separate urethral and vaginal openings; the perineum is normal aside from some minor irritation. (In males who present with UTI, the scrotal examination is important to rule out epididymitis.) Her vital signs are within normal limits. She is afebrile.

Pathophysiology of Urinary Tract Infection

The majority of urinary tract infections have an ascending route of origin. Despite good perineal hygiene, the perineum and urethral meatus are colonized by intestinal flora that can ascend the urethra into the bladder. Bacterial virulence factors and host susceptibility contribute to development and severity of infection.
Escherichia coli
accounts for approximately 75–95% of urinary tract infections (Gaylord & Starr, 2009).

Disturbances of bowel and bladder function (dysfunctional elimination syndrome) are common in children with urinary tract infections. A detailed elimination history is important to determine and treat this disorder. Successful management of urinary tract infections will not occur if the elimination pattern is not addressed (Koff, Wagner, & Jayanthni, 1998). Symptoms associated with dysfunctional elimination syndrome (DES) include urinary incontinence, fecal incontinence, constipation, dysuria, urinary frequency and urgency, posturing (such as squatting or crossing legs tightly) to avoid accidents, and infrequent or delayed voiding.

Obstruction and other anomalies of the urinary tract can present with UTI; these infections can be difficult to manage. Vesicoureteral reflux (VUR) is a condition of retrograde flow of urine from the bladder to the kidney. It is graded in order of severity I through V. Children with VUR may be at higher risk for significant infection and resultant renal scarring. Decreased renal function and hypertension can result from renal scarring. Approximately one third of siblings of children with reflux also have reflux, and 50% of offspring of mothers with reflux also have reflux (Elder, 2007).

Epidemiology of Urinary Tract Infection

Bacteruria can occur in all age groups; in the first year of life it is more common in males, especially if uncircumcised (1:47 compared to circumcised 1:445) (Schöen, Colby, & Ray, 2000). After the first year, it is more likely in females (10:1) (Elder, 2007). The short urethra is an accepted explanation for
the increased incidence of UTI in girls. By age 11, it is estimated that 1% of males and 3% of females will be affected by UTIs (Alon, 2006).

Social and Economic Factors

Urinary tract infections are common in children. Parents often do not understand the importance of antibiotic use and follow-up. Some believe that home remedies such as cranberry juice effectively treat urinary tract infections. Lack of insurance and difficulties with transportation also often preclude follow-up. These issues need to be respectfully addressed.

Are there lab tests you want to order?

With the symptoms Ashley presents with, a clean-catch, midstream urine specimen would be appropriate to obtain now.

Her urinalysis is leukocyte and nitrite positive today.

What other questions do you want to ask the parents and child to help make the diagnosis?

You want to ask the following questions:

•   How often does the child void? (Elimination disturbances)

•   Does your child have any stool incontinence or constipation? (Elimination disturbance)

•   Does the child have posturing behaviors, or attempts to delay voiding? (Elimination disturbance)

•   What symptoms has the child experienced previously?

You need to differentiate between upper tract infection (pyelonephritis) and lower tract bladder infections:

•   How were previous urine specimens obtained? Did the child urinate in a cup or was she catheterized? Where were the specimens obtained? (Rule out specimen contamination; the provider needs to determine if the specimens show true infection or a contaminate.)

•   Is there any family history of renal anomalies? (Determine genetic risk for renal anomalies.)

•   Does the child have any lower extremity pain or weakness? Are there any gait problems? (Neurologic disorders)

•   Have you tried any home remedies to help your child? (Homeopathic approach)

Mom responds that Ashley voids infrequently; she sometimes goes up to 2 hours after awakening in the morning before she urinates. During the day, she holds it until the last minute and sometimes they see her squatting or crossing her legs to avoid going to the bathroom. She has occasional damp spots in her underwear during the day, but is typically dry at night; during infections she has accidents both day and night.

The first infection was approximately 9 to 10 months ago. A clean-catch midstream specimen grew 100,000
Escherichia coli
. She did not have a fever, flank pain, nausea, or vomiting. Mom had taken her to a clinic because of the incontinence. She was treated with amoxicillin and her symptoms resolved. Six weeks later, mom noticed she had an episode of nocturnal enuresis. At that time, a repeat culture was done, which grew less than 50,000
Escherichia coli
. She was treated again, but still had occasional day accidents.

Mom reports Ashley’s bowel movements are infrequent and hard to pass. She has stool streaks in her underwear.

Approximately 2 months prior to this clinic visit, Ashley was seen in the local emergency department with a fever of 102°F. She was complaining of generalized abdominal pain, nausea, and a headache. She vomited several times. She was started on antibiotics and treated as an outpatient. Her urine culture grew greater than 100,000
Klebsiella pneumoniae
.

Mom had a history of urinary tract infections as a child, but does not recall being evaluated.

Making the Diagnosis

The differential diagnoses for urinary tract infection include differentiating among upper urinary tract infections (pyelonephritis), lower urinary tract infections, external perineal irritation, foreign body insertion, vaginitis, pin worms, renal calculi, hypercalcuria, constipation, and structural anomalies of the urinary tract such as obstruction or vesicoureteral reflux.

History and physical findings are consistent with the diagnoses of 1) a urinary tract infection, and 2) dysfunctional elimination syndrome. The urinalysis is both leukocyte and nitrite positive and should be sent to the laboratory for culture and sensitivity.

How a specimen is collected directly correlates to its validity: most valid is suprapubic bladder aspirate, second is sterile urethral catheterization, and third is clean-catch midstream. The least reliable is the bagged specimen (Gaylord & Starr, 2009).

Ashley has no known allergies. She has delayed voiding, posturing to prevent enuresis, and constipation, which are symptoms consistent with dysfunctional elimination syndrome. There is one documented upper tract infection with fever, nausea, and vomiting. Pyelonephritis may be indicative of structural abnormality and warrants additional evaluation. Structural abnormalities such as VUR, obstruction, or other anatomical defects may present as urinary tract infection (Gaylord & Starr, 2009).

Management

The treatment plan is determined by the findings of urinary tract infection, dysfunctional elimination syndrome, and any complications such as vesicoureteral reflux. It will be customized to the child’s age.

The goals are to:

•   Protect the kidneys from damage.