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Published on: July 18, 2017
Renal infection and vesico-ureteric reflux
1Department of Nuclear Medicine, Prince of Wales Hospital and Sydney Children's Hospital and University of New South Wales, Sydney, Australia. m.rossleigh@unsw.edu.au
Insights
Investigating childhood urinary tract infections (UTIs) involves imaging like ultrasound and (99m)Tc dimercaptosuccinic acid scintigraphy (DMSA). The debate centers on when to screen for vesico-ureteric reflux (VUR) based on DMSA results.
Area of Science:
- Pediatric Nephrology
- Diagnostic Imaging
- Urology
Background:
- Urinary tract infection (UTI) is a frequent childhood illness with ongoing diagnostic debates.
- Initial investigations typically involve ultrasound to rule out obstructions and structural anomalies.
Purpose of the Study:
- To review the current controversies and evolving roles of diagnostic imaging in pediatric UTI.
- To discuss the significance of (99m)Tc dimercaptosuccinic acid scintigraphy (DMSA) and vesico-ureteric reflux (VUR) detection.
Main Methods:
- Discussion of various imaging modalities including ultrasound, DMSA scintigraphy, and cystography (radiological and radionuclide).
- Analysis of differing clinical approaches to investigating pediatric UTIs based on imaging findings.
Main Results:
- Ultrasound is universally accepted as the first-line imaging for excluding obstruction.
- (99m)Tc dimercaptosuccinic acid scintigraphy (DMSA) is increasingly vital for diagnosing acute pyelonephritis and guiding antibiotic therapy.
- The necessity and timing of vesico-ureteric reflux (VUR) investigation, particularly cystography, remain debated, with varied thresholds for proceeding based on DMSA results.
Conclusions:
- The optimal diagnostic pathway for pediatric UTI requires careful consideration of imaging results, especially DMSA scans.
- While radiological cystography is the gold standard for detecting posterior urethral valves in males, radionuclide cystography offers advantages in other scenarios.
- Further research may clarify the most effective and least invasive strategies for managing childhood UTIs and preventing long-term sequelae.
Abstract:
Urinary tract infection (UTI) is a common disease of childhood. The investigation of UTI in children has been the subject of debate and controversy for many years. Most workers agree that the first imaging modality to be used should be an ultrasound examination to exclude obstruction, structural abnormalities, and renal calculi. The role of (99m)Tc dimercaptosuccinic acid scintigraphy (DMSA) in the diagnosis of acute pyelonephritis is becoming increasingly important. Many argue that if the DMSA study is normal at the time of acute UTI, no further investigation is required because the kidneys have not been involved and thus there will be no late sequelae. Others use the acute DMSA study to determine the intensity of antibiotic therapy. The importance of the role of vesico-ureteric reflux (VUR) is being debated. Some workers will only proceed to cystography to detect VUR if the DMSA study is abnormal, whereas others advocate a more aggressive approach. VUR can be identified by a variety of radiological and scintigraphic techniques. Although the radiological cystogram is the gold standard and is essential in the first UTI in a male patient, to exclude the presence of posterior urethral valves, radionuclide cystograms are advantageous in other situations. Suprapubic cystography techniques have been described to overcome the trauma of urethral catheterization but have not been widely accepted.
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