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Urinary Tract Infections: Decoding Pee Problems

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:

  1. Pain, burning, or stinging when peeing (dysuria)
  2. Having to pee a lot (frequency)
  3. Urinary accidents (especially noted in a previously potty-trained kid)
  4. Bed wetting (again noted in a previously trained child)
  5. Low abdominal pain or cramping
  6. Stinky pee
  7. Urine may be cloudy or even have blood
  8. Fever and/or shaking chills (more likely in kidney infections)
  9. Pain in the side or back (more likely in kidney infections)
  10. 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:

  1. The infection can spread to other parts of the body (usually the blood, causing sepsis)
  2. 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.

Adenovirus: This Virus Is Super Tricky

Adenovirus is going around. It’s a sneaky little virus (it can infect just about anywhere and happen anytime of the year). However, the sore throat, fever, pink-eye combo that happens most commonly in the summer is in full swing in our community now. The key to this little bug is prevention. Don’t get it in the first place. Wash your hands like crazy and make your kids do the same.

Adenovirus causes all sorts of problems

It can infect multiple organ systems, which makes it unique. There aren’t many viruses out there that can cause respiratory illness, GI illness (the vomit/diarrhea bug), conjunctivitis (pink eye), urinary tract infections, you name it. Stupid, but interesting random fact: the virus causes cancer in rodents, but not in humans. Go figure. Here’s the low down.

Kids hit the hardest

While anyone can get this nasty little bug, kids get the short end of the stick. Young children are affected the most. Interestingly, there is also a peak seen in military recruits (accounted for by their close quarters).

What are adenovirus symptoms?

This is the trick. Because adenovirus can infect all different parts of the body (and sometimes at the same time), it can present in all different ways.

  1. Respiratory symptoms: Cough, runny nose, sore throat, fever. The symptoms can be pretty severe and will even look like RSV. The key is what symptoms go together. If you have a case of bronchitis and conjunctivitis (pink eye), that is almost always adenovirus. Other viruses don’t usually give you pink eye with lower respiratory tract infections.
  2. GI symptoms (Gastroenteritis): Vomiting and diarrhea. It is quite common in the daycare setting.
  3. Urine/kidney symptoms: Painful urination, frequent urination, and blood in the urine.

How do you catch adenovirus?

The site of entry usually determines the site of infection. If the virus goes in the respiratory tract via inhaling infected droplets, you get a respiratory bug. If you ingest fecal material, you’ll get a GI (gastrointestinal) bug. I know the concept is gross, but this is how it works. Infected person A doesn’t wash his/her hands after going to the bathroom (or changing their infected child’s diaper) and touches the door handle. You come along and touch the infected door handle. Your hands now have infected material. When you later wipe your mouth, voila, you’re infected. It’s a hardy little virus and can survive a long time outside of a host (which means surfaces stay infectious for a long time). FYI, water can get infected also. Once again, here’s another reason to make sure pools are chlorinated properly.

How is adenovirus diagnosed?

There are fancy lab tests to diagnose adenovirus. Most of the time we don’t do them as there isn’t a cure and the tests are expensive. However, sometimes there are circumstances where testing is done (e.g., severe symptoms, young infants, prolonged fever, immunocompromised patients). The patients that we have specifically tested in our office over the last few weeks have all been positive for adenovirus. The location tested reflects the presenting symptoms. If the symptoms are respiratory, we usually use a swab that goes up the nose. If the problem is diarrhea or bloody urine, a stool sample or urine sample is tested. Blood tests are hit-and-miss whether they are helpful (as most people will have positive titers anyhow by the time they are school-aged). Most of the time, the diagnosis is made clinically. I feel like such a detective when I piece together some of the adenovirus unique infectious qualities, and make the diagnosis.

Is there a treatment?

Unfortunately, there is no cure to adenovirus. Since it is a virus, antibiotics don’t help. In fact, antibiotics will just make matters worse. Antibiotics screw with your child’s normal flora and contribute to antibiotic resistance. So don’t buy into the “just in case” mentality with antibiotics.

The treatment is completely supportive. In essence, you treat the symptoms to make the infected person feel better. If there is fever, treat the fever (with Tylenol or Motrin). If there is vomiting and diarrhea, push fluids to keep the person hydrated.

Should you take your child to the doctor?

I end up seeing a ton of cases of adenovirus in the office because what to do often isn’t clear cut. The problem is that the symptoms of adenovirus often cross over with more concerning illnesses that should be seen. For example, if your child has a sore throat, it is reasonable to ensure the infection isn’t strep (which has to see a doctor for antibiotic treatment). If your child has pink eye, you probable should get that checked out to make sure it isn’t bacterial and needs a drop. So you can see how it’s a difficult call for a parent to make. If the symptoms are severe, prolonged, or questionable you probably should take your child in (or if your child is under 2 months old). If you’re certain it’s adenovirus (e.g., another child of yours has already seen the doctor and been diagnosed), then you don’t need to see the doctor.

When are you out of the clear?

Now that you have a child infected with adenovirus at your house, when are you done with it? When can you stop worrying about the other kids in your house getting it? Here’s more bad news. Once exposed, it can take 2 days to 2 weeks to develop symptoms. To make matters worse, as already mentioned, the virus is really hardy and lives on surfaces a long time (toys, towels, light switches, etc). Unfortunately, that means more cleaning (add it to the never ending list, right?). It’s not uncommon for me to see families who have been dealing with this virus in one way or another for weeks and weeks in their houses. I’m sorry to be the bearer of the bad news.

One special subtype: the “super cold”

It’s worth mentioning, since it’s gotten a fair amount of press coverage over the years, there is one serotype (which is essentially a certain strain) of adenovirus called serotype 14 that is sometimes referred to as the “super cold.” When people get this strain, the symptoms tend to be very severe (with roughly 40% requiring hospitalization and half of those in the intensive care unit). This is diagnosed when specific testing is done (once again, getting to the severe cases).

Pee Accidents In A Potty-trained Child

If your child, who is fully potty trained, is starting to have daytime pee accidents, you should be concerned. The medical term is diurnal enuresis. It is not developmentally normal and generally indicates a problem. Now if your child has only been trained for a week, I wouldn’t consider that a consistently trained child. A newly trained child may be losing the motivation to stay dry (e.g., no more stickers or toy rewards). I would consider 6 months or longer a consistently trained child. Here are the common causes for kids to suddenly start peeing their pants.

  1. Urinary Tract Infections (UTIs): One of the most common causes of urinary accidents in girls because they have short little urethras (tube that drains the pee out of the bladder) and the pee hole is so close to the poop hole. It is easy for little girls to wipe poop over the pee hole and get infections. UTIs are very uncommon in boys because they have much longer urethras. UTIs usually have other associated symptoms, like painful urination, having to pee frequently, abdominal pain, and/or fever.
  2. Incomplete emptying of the bladder (the medical term is dysfunctional voiding): Sometimes kids get so distracted with activities that when they finally stop and run into the bathroom to go pee, they don’t take the time to fully empty the bladder. The bladder is a muscle, if it isn’t used properly, it can become somewhat dysfunctional.
  3. Diabetes Mellitus (DM): An important cause of urinary accidents in children. Diabetes causes sugars to be elevated. One of the ways the body tries to fix that is to increase thirst (the sugars essentially cause the fluids in the cells to shift). When you drink more, you pee more and sometimes so much so that you can’t control it. Kids with diabetes will often have weight loss, headaches, and/or mood irritability.
  4. Emotional Stress: Major stresses in a kid’s world can cause urinary accidents. Just about any life stressor can do it: parental divorce, death, moving, introduction of a new baby, someone perceived as mean, being bullied, fear, etc. Usually a parent can readily identify the life stressor, but occasionally they don’t know (e.g., if the child is afraid to say something about being bullied). Look for your child to be moody, acting out, withdrawn, clingy, or teary.
  5. Sexual abuse: This is a tricky one. On more than one occasion, I have had urinary accidents be the presenting symptom of a child being sexually abused. It can happen in just about any circumstance by just about anyone.
  6. Constipation: It may not seem like a readily apparent cause of pee accidents, but is actually relatively common. If there is a ton of stool, it may obstruct the outflow of urine or cause pressure on the bladder and trigger a sudden need to pee.

I read once that kids perceived wetting their pants in class as the number 3 most stressful life event (only after death of a parent and going blind). So believe me, your child is worried about wetting his/her pants also. It’s not a problem you should just wait and watch to see if it gets better on its own. Seek medical care.