Painful, frequent and urgent urination — they’re the telltale signs of a urinary tract infection, or UTI, something most pediatricians see on a regular basis. The approach to care is usually simple: urinalysis, a course of antibiotics, plenty of fluids and a discussion about proper hygiene. Most of the time, the infection clears up with no further issues.
For some kids, however, UTIs are an ongoing problem. Recurrent UTIs are of particular concern in boys, who are generally much less prone to them than are girls. When a boy and his parents visit your office multiple times complaining of UTIs, it may be a sign that something more serious than a common infection is at play, says Richard Yu, MD, a pediatric urologist in the Department of Urology at Boston Children’s Hospital.
Boys at risk for obstruction
Of primary concern in these cases is the possibility of a urinary tract obstruction. Such blockages can occur in the urethra, bladder, ureters or kidneys and impede the flow of urine, making it more difficult to clear bacteria from the urinary tract and leading to recurrent infections.
In boys, obstructions are typically the result of structural abnormalities in the urinary tract. About 1 in 8,000 baby boys will be born with a type of birth defect called posterior urethral valves (PUV), extra flaps of tissue in the urethra that block the normal flow of urine. Left untreated, PUV and other obstructions — such as a similar problem called anterior urethral valves (AUV) — can lead to recurrent UTIs, as well as complications such as bladder dysfunction, severe hydronephrosis and kidney failure.
About half of boys with PUV will also develop vesicoureteral reflux, which can cause urine to move backward into the ureters and kidney, increasing the risk of recurrent UTIs and possible kidney damage. “These conditions are generally very manageable if caught early with the right diagnosis using the latest pediatric imaging,” says Yu.
What to look for
In PUV and other types of urinary tract obstructions, recurrent UTIs may be the only major sign. When other symptoms do occur, they can include a weak urine stream, difficulty urinating, new onset bedwetting or daytime accidents and an enlarged bladder that can present as a palpable abdominal mass. “Referral to a specialist is recommended for all infants that have a documented febrile UTI and for children that have recurrent UTIs,” says Yu.
Urinary obstructions and structural abnormalities are best evaluated and treated by a pediatric urologist who is familiar with these disorders. Urologists may recommend a voiding cystourethrogram or other imaging studies to help identify structural causes of recurrent UTIs. The majority of cases of PUV and AUV are treated with a minimally invasive surgical procedure called endoscopic incision of the valves, which trims the excess tissue responsible for obstruction. Medical management may also be recommended. For children without urethral valves, treatment may only require ultrasound surveillance or preventative antibiotics. But, in some cases, surgical correction may be required.
“Identifying structural abnormalities of the urinary tract is critical since it can reduce the rate of recurrent UTIs and may prevent loss of kidney function,” says Yu.
Learn about the Department of Urology.
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