Urine problems (2 months to 12 years)

     

Urinary tract infection (UTI)

Consider UTI if

  • Young child — irritable, unexplained fever, poor feeding, vomiting, weight loss or poor growth
  • Older child — urinary frequency, dysuria (pain on passing urine), abdominal or flank pain, vomiting

Ask

  • Dysuria (pain on passing urine)
  • Passing urine more often than usual (frequency)
  • Abdominal pain or flank/loin pain
  • In boys
    • Red, swollen penis or foreskin — balanitis
    • Ballooning of foreskin on urination, poor stream — phimosis
    • Foreskin retracts behind glans and becomes trapped and extremely painful — paraphimosis

Check

  • Calculate age-appropriate REWS — AVPU, respiratory distress, RR, O2 sats, pulse, central capillary refill time, Temp
  • Weight, BGL
  • Head-to-toe exam
  • Growth assessment
  • Collect clean urine sample — Table 3.26
  • U/A — only look at leucocytes and nitrites when considering UTI
  • If positive nitrites and/or leucocytes OR high clinical suspicion of UTI (eg previous UTIs) — send urine for MC&S

Do

  • Follow Flowchart 3.6
  • UTIs in older children can sometimes be caused by sexual abuse
    • Urine test for STI not a good screening test for sexual abuse
    • Medical consult before using as an STI screen — see Child sexual abuse

Table 3.26   Collecting urine samples

Flowchart 3.6   Investigation and management of possible UTI

*Gentamicin doses

Follow-up

  • All urine MC&S results need to be seen by doctor for interpretation — Flowchart 3.7
    • Interpretation depends on collection method — always write collection method on pathology form
  • Medical consult for all children with confirmed UTI
  • Repeat U/A 1 week after completing antibiotics

Follow-up first UTI — proven by MC&S

  • Initial treatment with antibiotics — Flowchart 3.6
  • Renal ultrasound to check for structural problems in urinary system in babies under 6 months OR if complicated UTI — talk with paediatrician

Flowchart 3.7   Interpreting urine MC&S results

Blood or protein in urine

Post-streptococcal glomerulonephritis (PSGN)

Consider PSGN if

  • Moderate (2+) or more blood on U/A
  • OR macroscopic haematuria (visible blood in urine) — urine dark (tea colour)

AND

  • Oedema (swelling) of face or legs — check with parent/s or carer/s
  • OR unusual and fast weight gain (from oedema)
  • OR high BP for age — correct cuff size important for right BP measurement

Usual presentation is cola coloured urine and puffy face — most easily seen on waking, may not be obvious at other times

Do

  • Medical consult — may need to send to hospital for investigations (C3, C4, ASOT, Anti-DNAse B, UEC)
  • If high BP — medical consult to send to hospital urgently
  • Talk to paediatrician about need to
    • Give furosemide (frusemide) straightaway if BP very high for age 
    • Restrict fluids, give more furosemide (frusemide) or antihypertensive medicine during transfer
  • Notify PHU

Subclinical cases

  • Recent Group A streptococcal infection and blood on U/A — but no high BP or oedema (swelling)
  • Don't need to go to hospital but need to notify doctor and PHU
  • Medical follow-up at 12 weeks
    • Repeat C3, C4  to check return to normal 
    • Repeat U/A and BP
    • Weekly U/A not needed

Other causes of haematuria (blood in urine)

Microscopic — blood only seen on U/A

Often found in well child. Causes include fever, infection, kidney stones, other kidney problems, nappy rash, genital sores, injury. In many cases no cause found

Check

  • History of kidney problems
  • BP
  • U/A for protein
    • Repeat in 1 week
    • OR if sick with a fever — repeat after sickness resolved
  • Full head-to-toe exam, weight
  • Look for oedema (swelling)
  • Look for sores, inflammation, rashes in genital area (private parts)

Do

  • If high BP for age — urgent medical consult
    • Correct cuff size important for right BP measurement
  • If blood trace or 1+ on U/A, BP normal, no proteinuria (protein in urine), normal renal function — usually benign. Non-urgent medical follow up

Proteinuria (protein in urine)

If protein more than trace on U/A

Check

  • BP
  • Consider UTI, STI, etc
  • Send urine for ACR

Do

  • If high BP for age — urgent medical consult
    • Correct cuff size important for right BP measurement
  • If ACR high — medical/paediatrician consult

Vesico-ureteric reflux (VUR)

Urine flows from bladder back up to kidneys. VUR may be a cause of UTIs in babies.  It can only be diagnosed by ultrasound of the bladder and kidneys. All babies with a UTI must be referred for an ultrasound

  • Can cause kidney damage if severe
  • May need long-term antibiotics to prevent UTIs. Plan developed by paediatrician or paediatric urologist will include antibiotics and follow-up

Problems in boys

Balanitis

Infection of foreskin and glans penis. Common in young boys

Check

  • Swelling, redness, pain, fever (T more than 38°C)
  • Swab for MC&S

Do

  • Give trimethoprim-sulfamethoxazole oral — child 4+20mg/kg/dose up to 160+800mg — doses — twice a day (bd) for 5 days
  • If not getting better — check MC&S result, use antibiotic based on sensitivity
  • If repeated infections — medical consult
  • Encourage hygiene, washing with soap every day

Phimosis

Can occur after balanitis due to scarring of foreskin

Ask

  • Ballooning of foreskin when passing urine
  • Poor stream

Check

  • Tight foreskin (small hole)

Do

  • Use betamethasone valerate cream 0.05% twice a day (bd) for 3–4 weeks
    • Spread directly on foreskin

Follow-up

  • Review to check it is resolved
  • If not resolved — refer to surgeon

Paraphimosis

Foreskin retracted behind glans penis and gets stuck. Swollen penis, very painful

Do