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The role of bladder function in the pathogenesis and treatment of urinary tract infections in toilet-trained children

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Abstract

Urinary tract infections (UTIs) are a common reason for referral to pediatric specialists and the risk profile of these children is influenced by age, sex, and underlying urinary tract abnormalities. UTIs in toilet-trained children represent a different entity than confirmed, febrile UTIs that occur in infants, impacted by suboptimal bladder habits, bladder dysfunction, constipation, or a combination of these factors. A comprehensive literature search was conducted using PubMed and MEDLINE and search terms included recurrent UTI, VUR, bladder and bowel dysfunction (BBD), constipation, lower urinary tract symptoms, and voiding dysfunction. Common presenting symptoms of UTI in children include fever (> 38 °C) with or without “traditional” lower urinary tract symptoms (LUTS) such as dysuria, malodorous urine, frequency, urgency, and incontinence. However, many infections in older children are afebrile episodes—consisting primarily of LUTS—which may or may not be confirmed with biochemical and/or microbiological evidence. Therefore, when evaluating toilet-trained children with recurrent UTIs, it is paramount to consider dysfunctional elimination as an underlying cause, diagnose, and treat it prior to indicating surgical options, even in the presence of VUR or other anatomical abnormalities. Although the impact of bladder function on the risk of infections is important, so is the accurate diagnosis and initial evaluation. This review article will focus on an often overlooked yet critical factor: the impact of bladder function, particularly for toilet-trained children, as well as the importance of implementing bladder training strategies, aggressive management of constipation, and pharmacological management as necessary.

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Abbreviations

UTI(s):

Urinary tract infection(s)

fUTI(s):

Febrile urinary tract infection(s)

rUTI(s):

Recurrent urinary tract infection(s)

LUTS:

Lower urinary tract symptoms

CAP:

Continuous antibiotic prophylaxis

BBD:

Bladder and bowel dysfunction

VUR:

Vesicoureteral reflux

US:

Ultrasound

VCUG:

Voiding cystourethrogram

DMSA:

Dimercaptosuccinic acid

UDS:

Urodynamic studies

EMG:

Electromyography

PVR:

Post-void residual

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Authors and Affiliations

  1. Division of Urology, Hospital for Sick Children and Department of Surgery, University of Toronto, Toronto, Ontario, Canada

    Armando J. Lorenzo, Mandy Rickard & Joana Dos Santos

  2. Hospital for Sick Children, 555 University Avenue, Toronto, Ontario, M5G 1X8, Canada

    Armando J. Lorenzo, Mandy Rickard & Joana Dos Santos

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  1. Armando J. Lorenzo
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  2. Mandy Rickard
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  3. Joana Dos Santos
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Correspondence to Armando J. Lorenzo.

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1. c; 2. d; 3. e; 4. b; 5. e

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Lorenzo, A.J., Rickard, M. & Santos, J.D. The role of bladder function in the pathogenesis and treatment of urinary tract infections in toilet-trained children. Pediatr Nephrol 35, 1395–1408 (2020). https://doi.org/10.1007/s00467-019-4193-6

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