Skip to main content
SpringerLink
Log in

Recurrent urinary tract infections in young children: role of DMSA scintigraphy in detecting vesicoureteric reflux

  • Original Article
  • Published:
Pediatric Radiology Aims and scope Submit manuscript

Abstract

Background

Performing micturiting cystourethrography (MCUG) in young children with recurrent urinary tract infections is controversial with discrepancy among the major guidelines.

Objective

Previous studies have shown that a normal dimercaptosuccinic acid (DMSA) scintigraphy may avoid the need of performing MCUG for detecting vesicoureteric reflux in children with first febrile urinary tract infection. However, the role of DMSA for ruling out vesicoureteric reflux in children with recurrent urinary tract infections has not been studied.

Materials and methods

Approval from institutional ethical review committee was sought and the requirement of informed consent was waived. A total of 50 children under the age of 10 years with recurrent urinary tract infections underwent MCUG scan within 3 months of DMSA scan from January 2011 to September 2012 at our institution. Diagnosis of recurrent urinary tract infections and grading of vesicoureteric reflux was according to previously established standards. Abnormalities on DMSA scan – scarring, hydronephrosis and reduced differential renal function – were compared with presence of vesicoureteric reflux on MCUG.

Results

High-grade vesicoureteric reflux was noted on MCUG in 22 (44%) cases. The findings on DMSA included hydronephrosis and scarring in 25 (50%) and 25 (50%) cases, respectively. Abnormalities on DMSA scan for detecting the presence of high-grade vesicoureteric reflux on MCUG examination had sensitivity, specificity, positive and negative predictive values of 95.45%, 35.71%, 53.85% and 90.91%, respectively. The positive and negative likelihood ratios were 1.48 and 0.13 respectively.

Conclusion

DMSA scan had high overall sensitivity and negative predictive value with a low negative likelihood ratio for ruling out high-grade vesicoureteric reflux on MCUG, which may obviate the need of invasive MCUG along with its associated drawbacks.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. Shaikh N, Morone NE, Bost JE et al (2008) Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J 27:302–308

    Article  PubMed  Google Scholar 

  2. Larcombe J (1999) Urinary tract infection in children. BMJ 319:1173–1175

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  3. Arant BS Jr (1991) Vesicoureteric reflux and renal injury. Am J Kidney Dis 17:491–511

    Article  PubMed  Google Scholar 

  4. La Scola C, De Mutiis C, Hewitt IK et al (2013) Different guidelines for imaging after first UTI in febrile infants: yield, cost and radiation. Pediatrics 131:e665–671

    Article  PubMed  Google Scholar 

  5. Vivier PH, Sallem A, Beurdeley M et al (2013) MRI and suspected acute pyelonephritis in children: comparison of diffusion-weighted imaging with gadolinium-enhanced T1-weighted imaging. Eur Radiol 24:19–25

    Article  PubMed  Google Scholar 

  6. Riccabona M, Avni FE, Blickman JG et al (2009) Minutes of the ESPR uroradiology task force session on childhood obstructive uropathy, high-grade fetal hydronephrosis, childhood haematuria, and urolithiasis in childhood. ESPR Annual Congress, Edinburgh, UK, June 2008. Pediatr Radiol 39:891–898

    Article  PubMed  Google Scholar 

  7. Shaikh N, Hoberman A, Rockette HE et al (2012) Identifying children with vesicoureteral reflux: a comparison of 2 approaches. J Urol 188:1895–1899

    Article  PubMed  Google Scholar 

  8. Brader P, Riccabona M, Schwarz T et al (2008) Value of comprehensive renal ultrasound in children with acute urinary tract infection for assessment of renal involvement: comparison with DMSA scintigraphy and final diagnosis. Eur Radiol 18:2981–2989

    Article  PubMed  Google Scholar 

  9. Hardy RD, Austin JC (2008) DMSA renal scans and the top-down approach to urinary tract infection. Pediatr Infect Dis J 27:476–477

    Article  PubMed  Google Scholar 

  10. Herz D, Merguerian P, McQuiston L et al (2010) 5-year prospective results of dimercapto-succinic acid imaging in children with febrile urinary tract infection: proof that the top-down approach works. J Urol 184:1703–1709

    Article  PubMed  Google Scholar 

  11. Routh JC, Grant FD, Kokorowski PJ et al (2012) Economic and radiation costs of initial imaging approaches after a child’s first febrile urinary tract infection. Clin Pediatr (Phila) 51:23–30

    Article  Google Scholar 

  12. Cohen AL, Rivara FP, Davis R et al (2005) Compliance with guidelines for the medical care of first urinary tract infections in infants: a population-based study. Pediatrics 115:1474–1478

    Article  PubMed  Google Scholar 

  13. National Collaborating Centre for Women’s and Children’s Health (2007) Urinary tract infection in children: diagnosis, treatment and long-term management. RCOG Press. http://www.nice.org.uk/nicemedia/live/11819/36028/36028.pdf. Accessed 25 April 2014

  14. Newman TB (2011) The new American academy of pediatrics urinary tract infection guideline. Pediatrics 128:572–575

    Article  PubMed  Google Scholar 

  15. Riccabona M, Avni FE, Blickman JG et al (2007) Imaging recommendations in paediatric uroradiology: minutes of the ESPR workgroup session on urinary tract infection, fetal hydronephrosis, urinary tract ultrasonography and voiding cystourethrography, Barcelona, Spain, June 2007. Pediatr Radiol 38:138–145

    Article  PubMed  Google Scholar 

  16. Tseng MH, Lin WJ, Lo WT et al (2007) Does a normal DMSA obviate the performance of voiding cystourethrography in evaluation of young children after their first urinary tract infection? J Pediatr 150:96–99

    Article  PubMed  Google Scholar 

  17. Mori R, Lakhanpaul M, Verrier-Jones K (2007) Diagnosis and management of urinary tract infection in children: summary of NICE guidance. BMJ 335:395–397

    Article  PubMed Central  PubMed  Google Scholar 

  18. Novljan G, Kenig A, Rus R et al (2003) Cyclic voiding urosonography in detecting vesicoureteral reflux in children. Pediatr Nephrol 18:992–995

    Article  PubMed  Google Scholar 

  19. Papadopoulou F, Tsampoulas C, Siomou E et al (2006) Cyclic contrast-enhanced harmonic voiding urosonography for the evaluation of reflux. Can we keep the cost of the examination low? Eur Radiol 16:2521–2526

    Article  PubMed  Google Scholar 

  20. Lebowitz RL, Olbing H, Parkkulainen KV et al (1985) International system of radiographic grading of vesicoureteric reflux. Pediatr Radiol 15:105–109

    Article  CAS  PubMed  Google Scholar 

  21. Fernbach SK, Maizels M, Conway JJ (1993) Ultrasound grading of Hydronephrosis: introduction to the system used by the society for fetal urology. Pediatr Radiol 23:478–480

    Article  CAS  PubMed  Google Scholar 

  22. Sulieman A, Theodorou K, Vlychou M et al (2007) Radiation dose measurement and risk estimation for paediatric patients undergoing micturating cystourethrography. Br J Radiol 80:731–737

    Article  CAS  PubMed  Google Scholar 

  23. Glynn B, Gordon IR (1970) The risk of infection of the urinary tract as a result of micturating cystourethrography in children. Ann Radiol (Paris) 13:283–287

    CAS  Google Scholar 

  24. Preda I, Jodal U, Sixt R et al (2007) Normal dimercaptosuccinic acid scintigraphy makes voiding cystourethrography unnecessary after urinary tract infection. J Pediatr 151:581–584

    Article  PubMed  Google Scholar 

  25. Fouzas S, Krikelli E, Vassilakos P et al (2010) DMSA scan for revealing vesicoureteric reflux in young children with urinary tract infection. Pediatrics 126:513–519

    Article  Google Scholar 

  26. Conway PH, Cnaan A, Zaoutis T et al (2007) Recurrent urinary tract infections in childhood. J Am Med Assoc 298:179–186

    Article  CAS  Google Scholar 

  27. Panaretto KS, Craig JC, Knight JF et al (1999) Risk factors for recurrent urinary tract infection in preschool children. J Paediatr Child Health 35:454–459

  28. Saleh SI, Tohmaz MM, Alanezi FH (2007) Renal scarring and vesico-ureteric reflux in childhood urinary tract infection. Middle East J Fam Med 5:1–10

    Google Scholar 

  29. Rolleston GL, Maling TMJ, Hodson CJ (1974) Intrarenal reflux and the scarred kidney. Arch Dis Child 49:531

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  30. Hansson S, Dhamey M, Sigström O et al (2004) Dimercapto-succinic acid scintigraphy instead of voiding cystourethrography for infants with urinary tract infection. J Urol 172:1071–1074

    Article  PubMed  Google Scholar 

Download references

Conflicts of interest

None

Author information

Authors and Affiliations

  1. Department of Radiology, Aga Khan University Hospital, Stadium Road, Karachi, 74800, Pakistan

    Muhammad Awais, Abdul Rehman & Naila Nadeem

  2. Nuclear Medicine, Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan

    Maseeh Uz Zaman

Authors
  1. Muhammad Awais
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Abdul Rehman
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Maseeh Uz Zaman
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Naila Nadeem
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Muhammad Awais.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Awais, M., Rehman, A., Zaman, M.U. et al. Recurrent urinary tract infections in young children: role of DMSA scintigraphy in detecting vesicoureteric reflux. Pediatr Radiol 45, 62–68 (2015). https://doi.org/10.1007/s00247-014-3062-5

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00247-014-3062-5

Keywords

Search

Navigation