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The Radiological Investigation of Urinary Infections in Children

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The Radiological Investigation of Urinary Infections in Children Postgrad Med J: first published as 10.1136/pgmj.46.531.11 on 1 January 1970. Downloaded from Postgraduate Medical Journal (January 1970) 46, 11-18. The radiological investigation of urinary infections in children F. STARER M.R.C.P.E., F.F.R Consultant Radiologist, Westminster Children's Hospital, London, S. W. '-" Summary One hundred children with urinary tract infections were fully investigated radiologically. More than half showed abnormalities of the urinary tract. It is concluded that full investigation of the urinary Forty-one tract is justifiable at any age; it should be carried moles out in boys at the first infection, and in girls at the latest after the second infectioq, or if treatment did 40% not produce the expected cure. 27%/ Introduction Childhood urinary infections are a potent cause of by copyright. adult renal failure; recent improvements in the management of chronic renal disease only serve to emphasize the need for timely prevention. It has long been recognized that urinary tract infections, par- Fifty-nine ticularly if recurrent or resistent to treatment are femoles frequently associated with an abnormality of the urinary tract. Thus, Smellie et al. (1964) found structural or functional abnormalities in 50% of children with tract infections. The 50% urinary recogni- http://pmj.bmj.com/ tion of these abnormalities is important for success- 33% ful management, and depends largely on radiological investigations. These consist in the main of excretion pyelography and micturating cystography. Stansfeld (1966) has estimated the incidence of urinary Age (yeors) infections in the general population to be 0-17/1000 FIG. 1. Age distribution of 100 children investigated boys and 0-4/1000 girls. The investigation of such for urinary infections. large numbers provides X-ray departments with a on September 26, 2021 by guest. Protected great deal of work, and presents a considerable considerable selection had occurred before the child radiation burden to the population. We, therefore, came to us because the patient had first to be referred thought it would be of interest to review our own by his general practitioner to the hospital, and then findings in order to assess whether the expenditure by the hospital consultant to the X-ray department. of time, effort and radiation was worthwhile. Our policy has been to carry out pyelograms on all; cystograms are performed on all boys and on any The series girls in whom primary treatment was unsuccessful, For this purpose the records of 100 children with or who show any pyelographic abnormality. With urinary infections who had been fully investigated increasing experience, there has been a tendency to radiologically were reviewed. Criteria for diagnosis widen the indications for cystography, so that more were strictly observed, and correspond to those and more of these examinations are being carried described by Scott (1968). Ages ranged from birth out. All children in this series had both examinations, to 15 years (Fig. 1). The 100 records which were and this would tend to weight this series somewhat picked at random from the material available in the with a higher incidence of anatomical abnormalities X-ray department were unselected, but clearly compared with a completely random series. Postgrad Med J: first published as 10.1136/pgmj.46.531.11 on 1 January 1970. Downloaded from 12 F. Starer Techniques Hydronephrosis Standard, well-known techniques were used, but a The causes of hydronephrosis can be further few comments may be apposite. broken down as shown in Table 2. Pyelography TABLE 2 was carried out after the Pelvi-ureteric obstruction (7) Pyelography clearing gut Cause unknown 5 and under only mild dehydration. A minimum of Abnormal vessels 2 20 ml of contrast medium was used, even for Ureterocoele 2 neonates, always given intravenously. Intramuscular Pin-hole ureteric orifice 1 injection should be avoided. Since visualization of Urethral valve 1 renal outlines is we have never Exomphalos 1 very important hesi- Horse-shoe kidney 1 tated to use tomography to show the kidneys. A film Reflux 12 taken with the tube moving through a small arc adds Total 25 little radiation to the examination, and may on the contrary save a number of useless exposures. Small children must be well sedated for this examination. It will be seen that the commonest single cause of hydronephrosis is vesico-ureteric reflux. Reflux as a Micturating cystography common cause of hydronephrosis has been recog- nized only fairly recently, but the finding accords This was done under basal sedation; I consider the with other observers. For instance Shopfner (1965), use of general anaesthesia advocated by some in a review of 300 children with urinary infections, authorities to be nearly always unnecessary and found that dilatation of the pelvi-calycine system undesirable. The urethral catheter is passed under was more often due to reflux than to pelvi-ureteric strictly aseptic conditions, and infection from it has obstruction. He found that obstruction had been not been a Routine antibiotic cover was not problem. diagnosed in eighty-three children and led to seventy- by copyright. used. The bladder was viewed by image intensifica- four operations in 1953. Ten years later, after the tion and television monitor, and the image recorded importance of reflux had been recognized, obstruc- on a videotape recorder. The latter has advantages tion was diagnosed only five times during a period of over cine film: it can be viewed immediately and does 1 year, and all were operated upon. The mechanism not require any increase in radiation. The catheter whereby reflux causes hydronephrosis is not fully was connected by a drip-set to a bottle containing established. The degree ofpelvic dilatation caused by 20% diodone as described by Trapnell (1965), reflux into the pelvis is quite astonishing, and it may thereby maintaining complete sterility. One other be that the constant stretching of the elastic tissue requirement is a plentiful supply of patience, par- in the leads to its distention. pelvis finally permanent http://pmj.bmj.com/ ticularly in older children who cannot always Other suggestions have been put forward. Hodson & micturate to order. Edwards (1960) propose vascular compression as a factor, while Hutch, Hinman & Miller (1962) Results believe that distention of the pelvis may cause Table 1 summarizes the results found in 100 kinking at the pelvi-ureteric junction with ultimately children. permanent hydronephrosis. No doubt infection may also a but we have TABLE 1 play part, evidence amongst our own material (but not included in this series) that on September 26, 2021 by guest. Protected Hydronephrosis 25 infection is not an essential factor in the development Atrophic pyelonephritis 8 of hydronephrosis. Bladder diverticula 8 Next in was obstruction Bladder residue 8 frequency at the pelvi- Ureterocoele 2 ureteric junction. This should be diagnosed only in Calculi 2 the absence of reflux, and if stasis in the pelvis can Duplex kidney 5 be demonstrated by a retrograde pyelogram. (This Horse-shoe 1 is one of the few indications for performing this Ureteric reflux 43 examination. Improved excretion pyelography has made it largely unnecessary, and it is liable to cause In some children more than one abnormality was oedema of the ureteral mucosa with possible conse- discovered, and there were only thirty-five children quent infection.) In patients in whom no cause can who appeared normal in all respects: nine males and be demonstrated radiographically, one is dealing twenty-six females. either with a valvular mechanism at the junction, or Several of these abnormalities require further some abnormality in the dynamics of the upper discussion. ureter. An important factor in the flow of urine is Postgrad Med J: first published as 10.1136/pgmj.46.531.11 on 1 January 1970. Downloaded from Radiological investigation of urinary infections in children 13 normal peristaltic activity of the pelvis and ureter. Urine will not flow, even in the absence of obstruc- tion, if peristalsis is absent or abnormal. (Good examples of this are patients with peri-ureteric fibrosis, who develop severe hydronephrosis in the presence of a perfectly patent but rigid and aperi- staltic ureter.) It is highly probable that the hydro- nephrosis sometimes associated with duplex or horse-shoe kidneys also depends on abnormal pelvi- ureteric dynamics. It will be noted that abnormal vessels are thought to have been the cause of obstruction in two patients. At one time this was a widely accepted cause of hydronephrosis, but it has lately received much more critical consideration. More often than not a vessel running close to a dilated renal pelvis had no part in the genesis of the hydronephrosis, but our evidence suggests that occasionally the vessel is responsible. In these two patients the hydronephrosis was relieved by division of the responsible aberrant vessel; such a vessel is easily demonstrated by aortography pre- operatively. This examination, using the Seldinger technique of percutaneous femoral catheterization, can be carried out at any age from birth. There should be good spatial correlation between the by copyright. aberrant vessel and the point of obstruction before the obstructing role of the vessel is accepted. Obstruction to single calyces may also be caused by an arterial branch within the renal substance, or less a vein an commonly by accompanying artery (Fraley, FIG. 2. Posterior urethral valve and its effect on the 1966; Starer, 1968). Although several such cases kidneys: there is gross bilateral hydronephrosis. have been seen in our department, none happen to be included in this series. Another lesion in this group requiring special arises when an ectopic ureter is obstructed, with loss comment is urethral valve (Fig. 2). It is usually of function of part of a kidney, most usually the http://pmj.bmj.com/ stated that these children present with a poor urinary upper moiety.
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