Your five-year-old has been potty trained for two years now, but this week she has had several “accidents”. She also seems to be going to the bathroom more frequently and sometimes has a very strong, painful urge to pee. She tells you it burns when she urinates. These are all sure signs of a bladder infection. Here are some tips for you on how to recognize, treat and prevent bladder infections.
Another term for bladder infection that you may have heard is UTI – Urinary Tract Infection. Medical professionals use this term as an abbreviation for bladder infection.
The urine inside the bladder is normally sterile. There should not be any bacteria living there. However, the vaginal area and the penis both have bacteria that live in these warm, moist environments. Bacteria can start to move up the urethra (the tube that empties urine out of the bladder) and if they reach the bladder, can start to multiply. Normally, these bacteria are flushed out of the urethra by urination before this can happen. Sometimes, however, for a variety of reasons, the bacteria takes hold and causes an infection. The reason girls are more prone to bladder infections than boys is the female urethra is much shorter, therefore the bacteria has less distance to travel into the bladder.
- Irritation of the urethra – many substances, such as soap, bubble bath, stool, or clothing can cause soreness of the urethra, which makes it easier for bacteria to invade.
- Holding the urine in – this allows more time for the bacteria to get to the bladder and multiply within the bladder.
- Anatomic abnormality – during development in the uterus, the tubes that connect the kidneys to the bladder, or the urethra, don’t develop properly or aren’t hooked up right. This increases the risk of bladder infections. More on this later.
- Constipation – large amounts of stool sitting in the colon can press up against the bladder and urethra, thus making it more difficult for the bladder to drain completely. This allows bacteria to grow.
- Improper wiping – this can increase stool and bacteria around the urethra.
- Uncircumcised penis – a brief word here. Many people used to think that uncircumcised males were much more likely to have bladder infections. We now know this is not really true. While it is true an uncircumcised male has a higher chance of bladder infections during the first year of life, this risk goes away after age one. Therefore it is no longer true that circumcising males leads to a significant decrease in the risk of bladder infections.
- Pain or burning with urination.
- Frequent urination.
- Urgency – your child will have a very strong, painful urge to urinate.
- Fever – mild infections often won’t cause fever, but moderate to severe bladder infections that involve the kidneys do cause fever.
- Foul-smelling urine
Be aware that these symptoms don’t necessarily mean there IS a bladder infection, they just mean there MIGHT BE a bladder infection.
Occasionally the bacteria causing a bladder infection with ascend up into the kidneys and cause a kidney infection. This can be serious, since kidney infections can scar the kidneys. Most bladder infections DON’T turn into kidney infections, and a small scar in one kidney infection is harmless. But kidney infections are to be taken very seriously and treated promptly.
Here are signs that a bladder infection has turned into a kidney infection:
- The above symptoms.
- Lower back pain or side pain – this is where the kidneys are located.
- Fever – bladder infections often don’t cause fever. High fever indicates a possible kidney infection. Unlike “viral infections” in which the fever fluctuates between normal and very high, with kidney infections the fever stays high (usually 102º or higher) and your child looks and acts progressively sicker.
- Vomiting – this is also a common symptom when a kidney infection is present.
Checking a urine sample is the only way to diagnose a bladder infection. There is usually no outward sign on the penis or vagina that indicates an infection.
- For older children who have had several bladder infections and you are very familiar with the symptoms, your doctor may elect to simply treat with antibiotics instead of going through the trouble of checking a urine sample. This should only be done for older children with a known history of bladder infections. A urine should be checked in these children perhaps every other infection.
- Infants in diapers – you or a nurse can place a urine collection bag over the penis or vagina, then close the diaper over it. Be sure to meticulously clean off the area first with a wipe. This is very important since bacteria that normally live in this area can get into the urine sample and confuse the results. When your infant urinates, take off the bag and place it upright into the sterile urine cup. Don’t try to pour it into the cup since this might contaminate the sample.An alternative is to place your infant or child in a bath and wait for them to urinate. Have the sterile urine cup ready to catch some of the urine stream. This is more difficult, but the urine results are more accurate and less contaminated than a bag specimen.Bladder catheter – as you can imagine, using a bag is difficult and can often get contaminated. Inserting a tiny catheter tube into the bladder through the urethra is a way to collect as sterile sample quickly. It is painful, however, and should only be done when the doctor feels it is really necessary.
- Children – here’s how to collect a “clean catch, midstream” urine sample:
- Try to collect the first urination in the morning. It’s more accurate.
- Wipe off the penis or vagina well with a wipe.
- Have the sterile urine cup ready with the lid unscrewed.
- Tell your child what you’re going to do so she isn’t startled.
- Have your child start urinating. After two seconds, move the cup into the stream of urine. You only need to collect about a half inch of urine.
- It is important not to allow the first two seconds of the urine to go into the cup. This can cause contamination.
- Storing the sample – it is best to take the sample to the lab within 40 minutes of collection or else outside bacteria can start to grow in the sample. If needed, the sample can be placed in the refrigerator overnight, but a fresh sample is preferable.
You may have had some experience before with taking in a urine sample for testing. Here is an explanation of how the test works.There are three types of urine tests:
- Urinalysis (U/A) – this can be done in the doctor’s office or a lab. A dipstick is placed in the urine sample and up to ten different substances can be detected. There are three substances that show up positive during a bladder infection:
- Nitrite – this is a substance produced by bacteria.
- Leukocyte esterase – this is a substance produce by white blood cells (immune cells) when they attack bacteria.
- Blood – this will sometimes show up during a bladder infection.
This test just takes a few minutes. Depending on how strongly these substances show up, this test can be interpreted three ways:
- Bladder infection unlikely – if the U/A is normal, an infection is unlikely. However, occasionally this test can be completely normal during an infection.
- Bladder infection possible – if one or two substances show up weak, an infection may be present.
- Bladder infection probable – if two or three substances show up strong, your child probably has a bladder infection.
- Sometimes these substances can show up even when an infection is not present.
- Microscopic urinalysis (U/A micro) – this is usually only done by a lab. A drop of urine is examined under a microscope. Two things can show up in an infection:
- White blood cells – there usually are none or a few of these bacteria- fighting immune cells in the urine. If a lot show up, then there are probably bacteria there as well.
- Bacteria – often the bacteria will be seen with a microscope.
If no white blood cells or bacteria are seen, then there could still be an infection.
- Urine culture – this is the most accurate test to determine for sure whether or not an infection is present. It is usually only done in a lab. The lab puts the sample in an incubator. If any bacteria are in the sample, they will multiply and show up. However, it takes 24 to 48 hours for the bacteria to grow enough to be detected. Here is how the results are interpreted:
- No growth – if no bacteria grow within 48 hours, then there is no infection.
- Slight growth – if just a few bacteria grow, then they are probably not actually an infection.
- Large growth – if many of one type of bacteria grow, then this is definitely an infection.
- Contamination – if several different types of bacteria show slight to large growth, then these are probably bacteria that just live on the skin and inadvertently got into the sample and not an actual infection.
- Interpreting a contaminated sample – this poses a dilemma for the doctor. If an infection is present, but the sample was also contaminated, the contaminant bacteria will overgrow and hide the one type of bacteria that is causing the infection. Your doctor will decide whether or not to treat this as an infection depending on how suspicious he is. If the U/A and micro are positive for infection, but the culture is contaminated, your doctor may assume an infection is present. If the suspicion is low for infection, your doctor may repeat the urine culture to double check, or you can just observe the child to see if symptoms go away.
- Culture sensitivity – if one type of bacteria grows in the culture, the lab will expose the bacteria to a variety of antibiotics to see which ones the bacteria is sensitive too. This usually takes one day after the culture is positive. This helps your doctor decide which antibiotic is best for the infection.
You bring your child into the doctor’s office for a possible bladder infection. Here are the steps that are commonly followed:
- U/A is performed in the office.
- If normal, and child’s symptoms are mild, then you can probably just observe the child for the next few days. You can send a culture just to be sure.
- If positive for infection, and the child’s symptoms are moderate to severe, your doctor will probably send a culture to confirm, and start an antibiotic now to avoid allowing the infection to get worse. If the U/A is positive, but the child’s symptoms are mild, you may not start treatment while the culture is being done (since a positive U/A doesn’t necessarily mean there is an infection).
- Your doctor may also wait a few hours for the lab to run a microscopic U/A to help in the decision whether or not to start treatment while the culture is running.
- Be aware that a mild bladder infection can be left untreated for a few days without risking harm to your child while the culture is being done.
- If a urine culture is sent, you should call your doctor’s office after one and two days to check the results. If positive, call the next day again to check the sensitivity of the antibiotics. Don’t wait for your doctor to call you. The results may get lost in the shuffle and you may not automatically be notified of a positive culture.
- Antibiotics - your doctor will prescribe a 5 to 7 day course of an antibiotic, or longer for recurrent cases.
- Cranberry juice – this old remedy can be useful in addition to antibiotics. Drink three cups a day during the course of antibiotics. Cran- apple or another cranberry mix will also work. This juice has a substance in it that prevents the bacteria from sticking to the bladder, thus allowing the bladder to more easily flush out the bacteria.
- Drink lots of water – again, this helps flush out the bacteria.
- Urinate frequently – keeps the bacteria from multiplying inside the bladder.
- Warm bath – have your child sit in a warm bath. Have her urinate while sitting in the warm bath if she is too afraid to urinate because of the burning.
- Kidney infections – if your doctor suspects a kidney infection, the doctor may elect to give your child a shot of a strong antibiotic in the muscle to hit the infection harder, then continue with an oral antibiotic.
It is routine to check another urine culture about two weeks after treatment to make sure the urine has cleared up.
If your child has recurrent bladder infections, you should check a urine culture every one or two months to monitor for infections. If your child goes for six months without an infection, you can space out these urine checks per your doctor’s advice.
Some children may continue to have occasional infections throughout childhood. There are a variety of causes listed at the beginning of this discussion. Girls are more likely to have this problem than boys due to the shorter urethra.
- Avoid irritants – soap, bubble bath, and shampoo suds can irritate the urethra and wash away it’s protective mucus layer. Avoid bubble baths and don’t allow your child to sit in soapy bath water.
- Avoid tight underpants – this can irritate the urethra.
- Teach proper wiping – show your child how to wipe from front to back after having a bowel movement. For infants in diapers, be careful not to wipe around the vaginal area with a stool-contaminated wipe.
- Avoid constipation – click on it if your child may have this problem.
- Increase daily fluid intake
- Don’t hold in the urine
- Drink one glass of cranberry juice each day – this is very important.
- Double voiding – have your child try to urinate twice each time to make sure the bladder is completely empty.
- Antibiotic prophylaxis – this involves taking a small daily dose of an antibiotic to prevent bacteria from overgrowing. More on this later.
- Periodic urine cultures – you should check a urine culture every one or two months, then less often if your child is doing well.
Sometimes, a child can have an anatomic abnormality in the way the kidneys, bladder and urethra are hooked up that can cause recurrent bladder infections. There are three possible abnormalities:
- Tight or posterior urethral valves – the valve or sphincter that normally keeps the bladder from emptying can sometimes be too tight or in the wrong position. This prevents the bladder from emptying completely, and can make the urine back up and cause backpressure on the kidneys. This can cause the kidneys to dilate, which can lead to serious kidney damage. This dilation of the kidneys is termed hydronephrosis. Newborns born with this problem can either already have kidney damage from in utero backpressure, or can develop kidney damage rapidly during the first few months of life. This condition that occurs mostly in males is rare, but does need to be diagnosed quickly. One clue to this problem is a weak urine stream. The urine will dribble out instead of shooting out to hit you in the face.
- Vessico-ureteral reflux (VUR) – the problem here occurs where the urine tubes from the kidneys empty into the bladder. These tubes are called the ureters. A one-way valve normally prevents the urine in the bladder from going back up into the ureters and kidneys. Some children are born with immature ureter valves that allow the urine to go backwards and cause backpressure on the kidneys, or hydronephrosis. The backpressure on the kidneys isn’t as rapid and severe as the above problem, but over time it can damage the kidneys. Children will often outgrow this problem as the valves mature over several years. Some, however, do not.
- Abnormal kidneys or ureters – very rarely the kidneys, or the tubes that drain them into the bladder, can develop abnormally in a variety of ways. This prevents the urine from draining properly into the bladder and can lead to infections.
There are several different radiology tests that are used to look for structural problems involving the bladder and kidneys.
- Ultrasound – this is the same harmless test most pregnant women get to look at the fetus. It is painless and non-invasive. An ultrasound can tell us if there is a structural problem with the kidneys or ureters, or if any hydronephrosis (back-pressure) is present. It cannot tell us if there is VUR or a urethral valve problem.
- Voiding Cysto-urethrogram (VCUG) – a what? This test involves restraining an infant or child, inserting a catheter through the urethra into the bladder, injecting a dye into the catheter, pulling out the catheter, and allowing the infant to urinate the dye back out. Several x-rays are taken during the procedure. The dye outlines the bladder and urethra on the x-ray to show if any structural problem exists. If there is VUR, the x-ray will show the dye backing up through the ureters into the kidneys. This dye does not damage the bladder or kidneys, and it is flushed out quickly with urinating. This test is invasive and can be painful and scary for a child yet, it’s the only way to detect problems with the urethra and ureters. This test gives very little information about the kidneys
- Intravenous pyelogram (IVP) – dye is injected through an IV into the blood stream. The dye travels through the kidneys and into the urine, thus outlining the structure of the kidneys on x-ray. Several x-rays are taken. This test does not show VUR or urethra problems.
- Nuclear medicine scan – similar to an IVP, but this test shows the kidneys in such a way that checks the kidney function and checks for scars in the kidneys.
Except for the ultrasound, none of these tests sounds very fun, especially when it’s YOUR child. Deciding when testing should be done is difficult. You need to weigh the likelihood that an abnormality is there and how serious such abnormalities can be versus the trouble and trauma of putting your child through such testing. Here is the standard medical recommendation that most doctors may follow. Children should have an ultrasound and VCUG in these instances:
- Newborns who have a single bladder infection
- Infants less than one year of age who have a second bladder infection
- Older children who have had more than three or four infections
Your doctor may choose to be more or less aggressive than these guidelines. There is really no “right way” to decide.
If these tests are normal, but your child continues to have problems with infections, then a referral to a pediatric urologist or nephrologist is necessary. The specialist will decide if any further testing, such as an IVP, needs to be done. A urologist is a surgical specialist and a nephrologist is a non-surgical specialist. If there is an abnormality on these tests, your doctor may refer you to a specialist for appropriate treatment.
For children who have recurrent bladder infections, a daily low-dose of antibiotics can be given to control any bacteria that may get into the bladder. Prophylactic antibiotics are appropriate in the following situations:
- Children with known anatomic abnormalities that make them prone to infections.
- Children without abnormalities who continue to have infections despite all the above non-medical preventions.
Your doctor and you will decide how long to stay on prophylaxis. Typically children will take an antibiotic for six to twelve months, then come off of it and monitor the urine.