Figuring out what pee problems to worry about and what ones aren’t worthy of an office visit can be tricky for a parent. Every day in clinic I’m addressing urinary problems in kids. My own 5 year-old daughter has had two urinary tract infections in the past two years, but I have tested her urine probably 6 or 8 times. The risk of missing something is too great to ignore symptoms. Here’s the scoop on urine infections.

What is a Urinary Tract Infection?

A urinary tract infection (abbreviated UTI in medicine and not be confused with URI which is an upper respiratory tract infection or cold) refers to when bacteria gets into the parts of the body that deal with pee. The urinary system (in order that the urine goes) is made up of the kidney, ureter, bladder, and urethra). If a child gets an infection anywhere in the system, then the child has a UTI. Technically, in medicine we make a distinction between kidney infections and bladder infections. If the infection is in the urethra and bladder we called it cystitis. If the infection is in the kidney, we call it a pyelonephritis. In general, a pyelonephritis is considered more serious. It is worth noting that bacteria is NOT normal in the urinary system (unlike the GI-or intestines, where there is normal bacteria). Urine should be “sterile.” UTIs happen about 3 times more commonly in girls than boys.

What causes a UTI?

UTIs can happen in one of two ways: from inside the body or outside of the body. Bacteria can reach the urinary system from the blood. Since the blood doesn’t normally have bacteria in it either, this method of infection is very rare. The much more common way of getting a UTI is from the outside of the body and invading in the urethra. Usually bacteria from the gut (usually E. Coli) gets into the urethra from wiping the wrong way. The anal hole and urethral opening are right next to each other and it is really easy (especially for little girls who are learning to wipe) to wipe the poop into the urethra. Because of this mechanism, it makes sense that UTIs are much more common in little girls (the urethra is shorter and the opening is nearer to the anus). Most of the time, in a UTI, the bacteria that grows comes from the gastrointestinal (GI) tract.

Signs and Symptoms of UTIs

How a kid presents when infected has a lot to do with the child’s age. A baby may have nothing more than irritability and fever. Sometimes vomiting will be involved. An older child will usually present with all or some of the following:

Pain, burning, or stinging when peeing (dysuria)
Having to pee a lot (frequency)
Urinary accidents (especially noted in a previously potty-trained kid)
Bed wetting (again noted in a previously trained child)
Low abdominal pain or cramping
Stinky pee
Urine may be cloudy or even have blood
Fever and/or shaking chills (more likely in kidney infections)
Pain in the side or back (more likely in kidney infections)
Really ill appearing (also more likely in kidney infections)

How do I prevent UTIs?

The key to preventing UTIs is careful hygiene habits. When your baby is young, change diapers frequently. Be especially quick to change poopy diapers and careful to get all the feces out from between all the little folds in little girls.

When your child is old enough to start learning to wipe him/herself, take time to teach the child to wipe properly. It is usually not enough to tell a child not to wipe over the pee hole. It is better to reinforce wiping in the proper direction: front to back. To drive home the teaching, demonstrate to little ones how to “reach around” to their butt and wipe up towards the back.

Teach children not to “hold it” when they need to pee. Teach a child to go to the bathroom when the urge first hits. Having urine sit in the bladder a long time creates a set-up for bacterial overgrowth.

Don’t use bubble baths or strong soaps. The cutesy little character body washes are frequent offenders for causing irritation in little girls. When the skin gets irritated, you decrease your defenses. Use hypoallergenic products.

Stick with cotton underwear (over nylon). It is breathable and harder for bacteria to grow. Avoid really tight fitting pants (getting again to the breathable factor).

Make sure your child is pooping regularly. Chronic constipation can increase a child’s risk of UTIs.

Teens are a unique group with unique exposures (who may be sexually active). Teach teens not to douche, to pee after sex, and change pads/tampons frequently.

How are UTIs diagnosed and treated?

A UTI is diagnosed with a urine test. Typically, when you take your child in, the urine will be “dipped” and a urine analysis done. This tells the doctor if there is anything concerning in the urine (protein, leukocyte esterase, ketones, nitrates, white cells, etc.). This bedside test (done the day of the visit) will help the doctor determine if treatment should be initiated that day. If the urine is “clean” (all the markers are normal), your doctor will likely not start antibiotics. If the test is concerning, your doctor will likely prescribe antibiotics for your child. A followup test, called a urine culture, should be done as well. The urine culture will allow the doctor to identify the actual bacteria and adjust antibiotic choices as needed. The urine culture typically takes a few days as it needs time to grow the actually bacteria in the lab. The urine culture is the definitive test to diagnose a UTI. Treatment is with antibiotics.

Can I treat it with fluids or cranberry juice?

The short answer is NO. While fluids and cranberry juice are good for helping flush out the system, no amount of either will treat an infection. A true urinary tract infection will need antibiotics.

How is the urine obtained?

If the child is old enough to pee in a cup, that is the preferred method. Ideally, it would be a “clean catch.” This is done by first wiping the surrounding skin with a special cleansing cloth/wipe. It is preferable not to catch the first few drops of the pee, but rather “midstream.”

If the child isn’t potty trained, obtaining the urine gets trickier. It can be obtained by catheterization (i.e., inserting a small sterile tube up the urethra) or a “bagged urine.” The catheterization is considered superior because it is much more sterile (so the results are more likely to be accurate). However, it is much more invasive and painful for the child. The “bagged urine” involves putting a sticky bag over the urethra and hoping to catch some of the pee in the bag when the child urinates. This method is far less invasive, but much less reliable (poop can get into the bag, skin germs can contaminate the pee, etc.). The age of the child, the level of concern (for an actual UTI) and how truly sick the child looks will all help in aiding the doctor in determining the method to use. In my office, we do plenty of both methods. To be completely thorough, there is a third way of obtaining urine: the suprapubic catheterization and aspiration (essentially sticking a needle through the belly to the bladder). There are very few circumstances where this is actually ever done. (I’ve never done it myself.)

What are the risks if not treated?

UTIs should be addressed/treated right away. If left untreated:

The infection can spread to other parts of the body (usually the blood, causing sepsis)
The organs can become damaged (especially the kidneys)

What should I do if I suspect a UTI?

Untreated UTIs can cause damage to the urinary system. While watchful waiting is appropriate in a lot of cases of medical issues with kids, this is not one of those times. If you suspect your child may have a UTI, don’t hesitate to take your child to the pediatrician. If it is Friday night, waiting until Monday morning is not appropriate. A UTI on the weekend is certainly worthy of an urgent care visit. Just make sure that the urine is sent for a culture, so your pediatrician can help track down results and adjust medications if needs be. Don’t be discouraged if your child doesn’t end up having a UTI and you’ve bothered to go in. In young kids (especially early, potty trained girls), you’re bound to have a few false alarms. Look at the Wonnacotts, we’ve had 4-6 false alarms for the couple of true positives. The way I see it, I’d rather be safe than sorry.

Wetting the bed at night causes kids and parents a lot of stress. It is a really common problem, one that I see every week. Parents will kill themselves, setting alarms at night to help their kids get up and pee, buying all sorts of fancy devices, and trying all sorts of medicines to help “cure” it. The truth is, sometimes it just takes time. There are 2 major classifications of nighttime bed wetting (the medical term is nocturnal enuresis): primary and secondary. Someone with primary nocturnal enuresis has always wet the bed (since being a baby) and has never been night-trained. Secondary nocturnal enuresis refers to someone who has been trained/dry for at least 6 months, then starts night wetting again. Kids with secondary nocturnal enuresis should be evaluated for a possible medical problem.

How common bedwetting?

Fear not, you’re not alone. Most kids don’t night train right off. If often takes a while of being day trained before a kid can hold it at night. The AAP (American Academy of Pediatrics) says 20% of 5 year-olds, 10% of 7 year-olds, 5% of 10 year-olds, and 1% of 15 year-olds have nocturnal enuresis.

Bedwetting causes

There are many potential causes of bedwetting:

Hormones: ADH (or antidiuretic hormone) is supposed to make it so your body doesn’t make as much urine at night. If you don’t make enough hormone, you’ll make too much urine.
Genetics: There is a strong family link to bedwetting. Parents are always reluctant to want to admit to being bedwetters themselves, but it helps explain when kids have trouble with bedwetting. Be more patient if there is a family history of bedwetting.
Bladder problems: If the bladder is tiny or has spasms, there can be problems holding urine.
Deep sleepers: Some people sleep so deep that they just don’t seem to wake when the body senses a need to pee.
Stress: Major life stressors can cause a kid to pee at night. (This usually falls into the category of secondary enuresis though).

Evaluation and Treatment

Depending on the cause, the evaluation may involve questions, a physical exam, and urine analysis. Treatment entirely depends on the cause of the bedwetting, but is often nothing more than reassurance and waiting for time to resolve it. On occasion, your doctor may recommend medications to use for times when wetting the bed may be particularly stressful socially (e.g., a sleepover, boy scout camp). It is worth knowing that nocturnal enuresis has a 15% natural resolution rate per year (e.g., of a 100 kids that wet the bed, 15 of them will stop on their own each year).

Practical bedwetting solutions

I am a practical person at heart. If I tell you that your 5 year-old may wet the bed for the next decade (because dad was a bedwetter), you don’t have to go crazy washing sheets for the next 3,650 nights. Put a Pullup (Huggies) or an UnderJam (Pampers) on your kid at night. I usually tell kids, no underwear until they have been dry for a month. Make the kids handle the pee problem themselves (over age of 5): take off the wet pull up, throw it away, use a wet washcloth to clean the skin or shower (no one wants to smell like pee), and put on clean underwear. Make it a very matter-of-fact situation that just gets quietly addressed. Make sure a kid is never made fun of or teased for it, but empower him/her to handle it independently. Hang in there, this too shall pass.

Tag: peeing the bed

Urinary Tract Infections: Decoding Pee Problems