Introduction
Urinary tract infections (UTIs) occur when bacteria find their way into the urethra, ureters, bladder or kidneys. It is more common in girls (8.4%) than boys (1.7%). UTI accounts for 5%-10% of febrile conditions (fever) in children up to 24 months, with a recurrence rate of 10%-30%. Frequent or recurrent UTIs refer to repeated UTIs in children, with two or more UTI episodes occurring within 6 months or three UTI episodes in a year. If treatment is not given on time, it can cause kidney damage, particularly in children less than 6 years old. Recurrent UTIs are associated with kidney scarring, which can cause long-term complications, such as hypertension and kidney function impairment. Considering the fact that, except for fever, children less than 2 years old do not exhibit any apparent symptoms of UTI, it is crucial to recognize recurrent UTIs and their risk factors and seek timely treatment.
Causes of recurrent UTIs
Recurrent UTIs are of serious concern as every repeat infection increases the risk for health problems. Some of the causes of UTI are discussed below.
Bladder and bowel issues: Bacteria get flushed out of our bodies with regular urination. Children have the habit of holding urine for a long time, do not completely empty their bladders or do not relax while urinating. Holding the urine allows bacteria to grow. Some children do not drink enough water or fluids to produce enough urine to flush the bacteria out of their bodies. Lack of hydration also leads to bowel problems such as constipation.
Urinary tract abnormalities: Developmental abnormalities of the kidney and urinary tract; kidney stones; abnormal bladder development; damage to the nerves that control storage and emptying of urine or the presence of structures that block the flow of urine, can cause recurrent UTI.
Improper hygiene: Poor toilet habits and improper hygiene, such as wiping from back to front and not washing hands after using the toilet, contribute to recurrent UTIs.
Non-completion of antibiotic therapy: When the antibiotic therapy prescribed by the doctor for UTI is not completed, the chances of UTI returning are high.
Vesicoureteral reflux (VUR): In this condition, the urine flows in the reverse direction, from the bladder to the ureters. If urine having bacteria flows back into the kidneys, it can cause pyelonephritis (kidney infection).
Hydronephrosis: If urine flow is blocked (e.g., blocked ureters) or the urine builds up in the kidneys (severe VUR), it causes the kidneys to swell, leading to a condition called hydronephrosis.
Symptoms
- Frequent urination
- Pain while urinating
- Blood in the urine
- Foul-smelling urine
- Fever and chills
- Pain on the sides or the back, suggesting the infection has spread to the kidneys
Long-term consequences of recurrent UTIs
Recurrent UTIs usually do not pose any long-term health problems in most children. However, repeated infections can damage the kidneys and cause kidney scarring. Kidney scarring can lead to high blood pressure and protein loss in urine. In some cases, kidney scarring may progress to chronic kidney disease that requires dialysis.
Diagnosis methods
A paediatric urologist will determine the underlying cause of recurrent UTIs. In addition to urine analysis/culture and blood tests (kidney function tests), the following tests are conducted to identify the underlying cause of recurrent UTI.
Ultrasound: An ultrasound can provide details on the kidneys and urinary bladder. Structural abnormalities of the urinary tract are found on ultrasound scan in almost a third of the children diagnosed with UTI.
Micturating cystourethrography (MCU): This test is an X-ray procedure to identify VUR and bladder abnormalities. A contrast material is passed through a tube to fill the bladder. The child is instructed to urinate, and simultaneously, X-ray images are collected to check the reverse flow of the contrast into the ureters.
Nuclear scan: Radioactive material is injected into a vein to assess kidney shape and function. It can identify damaged kidney tissue and how the urine flows.
Treatment
- Careful monitoring suffices for many children
- Treatment for constipation and developing the habit of emptying the bladder every 3-4 hours
- Antibiotic therapy for VUR
- Surgery for urinary tract abnormalities
Conclusion
Recurrent UTIs can occur due to structural (VUR or urinary tract abnormalities) or functional (bowel and bladder issues or dysfunctional voiding) defects. Recurrent UTIs require evaluation as frequent infections can cause kidney scarring, which can lead to high blood pressure, protein loss or chronic kidney disease. Tests, such as ultrasound, MCU and nuclear scan, are useful for detecting urinary tract abnormalities that contribute to recurrent UTIs. Based on the diagnosis, treatment may involve bathroom visits every few hours, constipation medication, antibiotics or surgery. Parents should be aware of the symptoms and consult the doctor immediately for further evaluation if the symptoms occur frequently.
