What is the connection between UTI & VUR?

Suspect VUR when there is a febrile UTI

Febrile urinary tract infections (fUTIs) are the key defining symptom of vesicoureteral reflux (VUR).1 In imaging studies conducted to investigate the cause of UTI, VUR is the most common abnormality detected.2

UTI prevalence in children
  • UTIs are the most common serious bacterial infection in children3
  • About 1/3 of children with UTI have VUR3
  • About 8% of girls are affected by UTIs before the age of 74
  • About 2% of boys are affected by UTIs before the age of 74
  • 5-7.5% of unexplained fevers in infants are caused by UTI5

The presence of fever increases the probability of kidney involvement and is associated with an increased likelihood of underlying nephrourologic abnormalities.6

Febrile UTI (fUTI) risk factors7
  • Toddler girls
  • Uncircumcised boys < 1 year old
  • White race
  • Infrequent voiding
  • Constipation
  • Vesicoureteral reflux
  • Lower urinary tract abnormalities
Febrile UTI (fUTI) symptoms
  • Fever – may be the only symptom8
  • Abdominal, back or side pain8
  • Nausea, vomiting and occasional diarrhea8
  • Frequent or urgent urination9
  • Dysuria (pain during urination)9
  • Strong-smelling urine9
  • Incontinence9

In general, symptoms present differently in children depending on age.

Recurring febrile UTIs trigger screening and diagnosis of VUR2
  • Approximately 30-50% of children are diagnosed with VUR after their first confirmed UTI10
  • The reflux rate is 54% among girls ages 1 to 3 years with a history of febrile UTI11

The risk of UTI recurrence is greater when there is underlying VUR, especially for higher grades of VUR.12

  • In one study, children with VUR grades II-IV were followed for 2 years and the risk of febrile UTI recurrence was 30%13
  • In the presence of VUR, there is a greater probability that the UTI involves the kidneys8

The risk of kidney scarring associated with VUR increases with each UTI and is greater during the first 3 to 5 years of life.14

Although kidney scarring may begin early in life, the consequences can last a lifetime and can include early onset hypertension and end-stage renal disease.8

References:

  1. Läckgren G, Stenberg A. Endoscopic treatment of vesicoureteral reflux: current practice and the need for multifactorial assessment. Ther Adv Urol. 2009;1(3):131-141. DOI: 10.1177/1756287209342731
  2. American Academy of Pediatrics Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children. Pediatrics. 1999;103(4 pt 1):843-852. DOI: https://DOI.org/10.1542/peds.2011-1330
  3. Hoberman A, Keren R. Antimicrobial prophylaxis for urinary tract infection in children. N Engl J Med.2009;369:18. DOI: 10.1056/NEJMe0907623
  4. Jakobsson, B., Esbjorner, E. and Hansson, S. Minimum incidence and diagnostic rate of first urinary tract infection. Pediatrics. 1999;104:222-226. DOI: 10.1542/peds.104.2.222
  5. Girodias JB, Bailey B. Approach to the febrile child: a challenge between bridging the gap between the literature and clinical practice. Pediatr Child Health. 2003;8(2):76-82. DOI: 10.1093/pch/8.2.76
  6. Montini G, Tullus K, Hewitt I. 2011. Febrile urinary tract infections in children. N Engl J Med. 365:239–250. DOI:10.1056/NEJMra1007755.
  7. Gondim R, Azevedo R, et al. Risk factors for urinary tract infection in children with urinary urgency. Int Braz J Urol. 2018;44:378-383. DOI: 10.1590/S1677-5538.IBJU.2017.0434
  8. Elder JS. Vesicoureteral reflux. In: Kliegman R, Nelson WE, eds. Nelson Textbook of Pediatrics. 19th ed. Philadelphia, PA: Elsevier/Saunders; 2011:1834-1838.
  9. Fisher DJ, Steele RW. Pediatric urinary tract infection. Medscape.
  10. Jacobson SH, Hansson S, Jakobsson B. Vesico-ureteric reflux: occurrence and long-term risks. Acta Paediatr. 1999;88:22-30. PMID: 10588268
  11. Jodal U. The natural history of bacteriuria in childhood. Infect Dis Clin North Am. 1987;1(4):713-729. PMID: 3333655
  12. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. 2008;122(5):1064-1071. DOI: 10.1542/peds.2007-3770
  13. Pennesi M, Travan L, Peratoner L, et al. Is antibiotic prophylaxis in children with vesicoureteral reflux effective in preventing pyelonephritis and renal scars? A randomized, controlled trial. Pediatrics. 2008;121(6):e1489-1494. DOI: 10.1542/peds.2007-2652
  14. Sherbotie JR, Cornfeld D. Management of urinary tract infections in children. Med Clin North Am. 1991;75(2):327-338. DOI: 10.1016/s0025-7125(16)30457-6
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