What is the most appropriate antibiotic for a urinary tract infection? When does a patient with penile adhesions need to be referred? Seth Alpert, MD, pediatric urologist at Nationwide Children’s Hospital, addresses these and other common concerns.
Seth Alpert, MD, (@salpert93) a member of the Section of Urology at Nationwide Children’s Hospital, recently conducted a Twitter chat for primary care providers, answering questions he often receives from them. Below is an adapted version of the chat.
Nationwide Children’s hosts regular peer-to-peer chats through @NCHforDocs. Search #PedsMedChat for past conversations, including ones on interventional radiology, cancer predisposition in pediatrics and avoiding physician burnout.
Q: Is empiric antibiotic therapy for suspected urinary tract infection still appropriate in light of concerns about over-prescription and resistance?
A: Yes, when pyelonephritis or cystitis is presumed based on symptoms, but UTI in children should always be confirmed with a urine culture. A delay in initiating antibiotics can be associated with renal scarring with recurrent UTI. Previous culture-confirmed UTIs and susceptibilities may also help guide empiric therapy. But otherwise, consider waiting on a culture first if there is no fever, vomiting, flank pain, or other characteristic symptom.
Q: If I decide to use antibiotic therapy for UTI, which antibiotic should I use?
A: That’s becoming more complicated. The most common UTI pathogen is E. coli, and E. coli resistance to amoxicillin and TMP-SMX is growing. So first, check local susceptibility patterns. That said, my colleagues in Urology, Nephrology and Infectious Disease created a guide to diagnosing and managing UTI, and we have some prescription recommendations as part of it (e.g. cephalexin for patients <12 years with suspected pyelonephritis or cystitis). Download that guide.
Q: When should a patient with penile adhesions be referred to a urologist?
A: First, we need to differentiate between adhesions and bridging. Adhesions are common after neonatal circumcision, when inflamed skin edges may stick together. Applying a topical steroid cream (i.e. Betamethasone (0.05%)) twice daily for several weeks with manual retraction is often successful. Bridging is true skin fusion and won’t respond to steroid cream. When there is bridging, or particularly dense adhesions, referral to a urologist is appropriate as a procedure usually is needed.
My colleagues and I recently published on an office-based solution to a related circumcision complication, cicatrix. It’s less common than adhesions but referral is usually indicated to treat https://www.ncbi.nlm.nih.gov/pubmed/29980391
Q: What is the difference between an undescended and retractile testis?
A: An undescended testis (UDT) is abnormal. It can’t be brought into the scrotum on exam or won’t stay there with manipulation. A retractile testis is a normal variant and can be brought into the scrotum after the cremasteric reflex is fatigued. A UDT needs surgery but a retractile testis does not.
Q: At what point does an undescended testis become a concern? Why is it a concern at all?
A: As a reminder, the American Urological Association suggests palpating testes for quality and position at each well-child visit. An infant without spontaneous testis descent into a normal scrotal location at 6 months of age should be referred for a surgical evaluation.
A well-done physical exam is superior to imaging in determining testis location and any spermatic cord tension. An ultrasound isn’t needed for UDT except in rare cases with older and/or very obese boys when exam may be difficult.
We treat for two main reasons: there is a higher relative risk of cancer later in life for undescended testes, and early surgery can help preserve future fertility. Torsion and trauma are also concerns.
Q: We are seeing more cases of urinary stone disease in pediatric primary care. Is treatment of acute events and advice about diet and hydration enough or is there more to consider?
A: As my Nephrology colleagues say, it’s increasingly clear that a stone can herald other problems – cardiovascular disease, low bone density, chronic kidney disease. Some of us even specifically take a fracture history during stone evaluation. So even if a child passes a stone with conservative management, and this was the first such episode, the child still needs a full evaluation by nephrologists and/or urologists.
Treating the stone itself often isn’t enough in kids. Nationwide Children’s has a multidisciplinary Stone Clinic each month where patients can see both Urology and Nephrology in the same place and the same time to coordinate and consolidate care.
Q: When should renal ultrasound be done after birth for prenatal hydronephrosis?
A: Infants with prenatal unilateral hydronephrosis should have renal ultrasound (including bladder images) at 3-6 weeks after birth. Postnatal ultrasound soon after birth may underestimate the degree of hydronephrosis due to dehydration of the newborn. An infant (especially male) with bilateral hydroureteronephrosis consistent with bladder outlet obstruction should undergo ultrasound evaluation and voiding cystourethrogram (VCUG) promptly after birth with involvement of urology specialists if abnormalities are found.
Q: When should a VCUG be ordered after UTI is diagnosed?
A: A child 2-24 months of age with a first febrile UTI should have a renal ultrasound. If the ultrasound is normal, no other imaging is needed.
If the ultrasound shows hydronephrosis, hydroureter, scarring, or findings that suggest high-grade vesicoureteral reflux or obstructive uropathy (i.e. uroepithelial thickening), then a VCUG is indicated.
After a second UTI, especially with fever, a VCUG should be ordered to rule out reflux. If there is no reflux, then preventative measures should be initiated, such as genital hygiene; recognition and aggressive treatment of constipation or voiding dysfunction; and/or addressing phimosis in uncircumcised boys.