What Causes Urinary Problems In Children

Urinary tract infection

Urinary tract infections are reasonably common, especially in girls. Symptoms include pain when passing urine, fever, blood stained or cloudy urine, which may also be strong smelling. Rarely your child may have difficulties even initiating a urinary flow and not able to pass urine at all.

It’s common for bacteria to reside in the genital and perineal area (underpants area) however most bacteria are relatively harmless. Usually the bacteria that’s found in your child’s feces is what’s resides in this area, despite washing each time they have bowel motion.  When there is an “opportunity”, some bacteria can go up the child’s external “water-pipe” and cause trouble “inside”. The bacteria usually enter the urinary tract through the urethra, from outside.

With the above symptoms, your child will need to see a doctor and a urine sample taken to confirm that its truly a urinary tract infection, and if so, antibiotics should be started. If severely ill, its best to treat your child with intravenous antibiotics at a hospital.  When there is confirmed infection for the very first time, an ultrasound scan of the kidneys and the bladder should be done to look for any structural abnormalities. Most infections can be treated safely with antibiotics.

If the ultrasound suggests a structural abnormality, it is best to see a child surgeon, the timing of which is dependent on the response to the antibiotics. With poor response or a significant issue like a blockage to the urinary system with a stone, for example, its an urgent referral but something like a vesico-ureteric reflux is an outpatient visit once the infection is settled. The aim is to prevent anything that may cause permanent irreversible damage to the kidney(s).  

Urinary tract stones

This, fortunately, is rare for children in Malaysia. Poor fluid intake, recurrent urinary tract infections or admission to the intensive care as a premature baby in the early years are factors that could contribute to stones formation in children. It’s extremely rare for children to develop stones due to a “chemical imbalance” (metabolic). The problem with stones is that it can cause obstruction to urine flow. This can then lead to infection in the stagnant pool of urine. Both the obstruction or the infection can cause irreversible kidney damage.

Symptoms of stones in the upper part of the urinary tract (kidney and ureter) are loin pain (side of the tummy) which is sometimes sharp and colicky (comes and goes), blood in the urine, pain with passage of urine (radiating from the loin to the groin) or smelly/ cloudy urine.  Stone in the bladder, could present with most of the above symptoms or with similar pain but in the lower abdomen and perhaps with intermittency of urine passage (stop and start).

It’s crucial that the urinary system is not blocked or to have infection towards the kidneys (in a stagnant pool of urine), in both these situations it likely to cause damage to the kidney(s).

With any of the above symptoms, its best to take your child to a hospital with a child surgeon. Urine test and an Ultrasound scan is usually done in the first instance. The urgent issues are to relieve any obstruction or to treat any infection so as to prevent kidney damage. Minimal intervention is always the aim but with an obstructing stone, the drainage need to be reestablished to avoid kidney injury, therefore a surgical procedure such as inserting a stent or tube to bypass the obstruction is needed.

Foreskin problems – infection or scarring

Most boys are born with tight foreskin which cannot be retracted over the glans (head of the penis). This is called phimosis and this is referred as physiological phimosis as its normal. At the age of 5 years, almost 10% of boys will still have this and 5% at 10 years, all of whom are still normal. Only about 1% of all boys will run into trouble with physiological phimosis past puberty and they are the ones who need a circumcision to avoid issues as an adolescent.

With the phimosis, it’s difficult to clean under the skin and there will be some whitish secretion from the skin collecting there. They can appear as pearly lumps that may be visible through your boy’s foreskin, called smegma. This however can cause infection under the foreskin (balanitis). With infection here, the treatment is to soak the penis in a warm salt water bath and applying topical antibiotics cream into the foreskin (see your GP), as long as your boy can pass urine, albeit with a little pain and hesitation. This will get better and usually the skin will get back to normal. If the foreskin returns to normal in a few weeks, there is no need for surgery. Some boys may get recurrent infections here but this is also thought to be beneficial to help with the foreskin separating for the glans of his penis. If there is scarring or thickening of the skin (pathological phimosis or abnormal foreskin), then your boy will require a circumcision.

A child who cannot pass urine or is having difficulties emptying his bladder or has a scarred foreskin, progressively making it harder to pass urine should see a paediatric surgeon urgently, at the hospital emergency department.

Obstruction of the upper urinary tract

(Antenatally diagnosed kidney dilatation)

The most common cause of upper tract obstruction is at the pelvi-ureteric junction. (PUJ obstruction) (junction between the pelvis, the collecting funnel at the kidney to the tube that leads this to the bladder, the ureter). This is mostly congenital or something your child is born with. Very occasionally, this is due to some scarring after birth (non congenital). The symptoms that is caused by dilated kidney pelvis may be intermittent pain over that area or possibly urine infections.

Antenatal pick up of PUJ obstruction is increasing in number. Unless the growth of the kidney is effected, there is little to be done during the antenatal period other than regular scans to monitor. Once baby is born, a baseline ultrasound scan is done to have an idea of size and for comparisons with subsequent scans and so we can detect any changes or decide on the need to intervene surgically. Further scans like a nuclear isotope scan is done to assess the function of their kidneys and how good the urine flow is across this junction before the decision for surgery. Unless infected or with acute deterioration, your child should be seen by a pediatric surgeon soon after birth and followed up in the outpatient clinic setting. With the acute setting, surgery is usually done immediately to release the obstruction and reduce the risk of significant kidney damage.

For the less acute situation, follow up scans are done and if there is worsening of the swelling with poor urine flow across the PUJ, a keyhole surgery with minimal incisions on the tummy can be done to rectify the problem.   

Vesicoureteric reflux (VUR)

This is a condition where the natural “valve” between the ureter and the bladder is faulty. What happens as a result is that when the child passes urine, the urine comes out through the urethra externally and also some urine refluxes up via the “faulty” valve and up the ureter towards the kidney. This can be single sided or on both sides. There are various degrees to this reflux problem, from the milder grade 1 to the worst, grade 5, vesicoureteric reflux. VUR predisposes the child to urinary tract infection as their bladder is never empty at any one time. Infected urine that is pushed towards the kidney may cause irreversible kidney damage and scarring. The aim with this condition is to prevent urinary tract Infection or even to reduce the degree of reflux to lower grades so that we don’t get infected urine reaching the kidney and cause damage there.

For this reason, every child who has the first episode of urinary tract infection should have an ultrasound scan to exclude this or any other structural problems.

The other investigation required for diagnosis and treatment management is a micturating cystourethrogram which is a dye test injected into the bladder via a tube, to demonstrate reflux and its severity. VUR can also be diagnosed on antenatal scans, though the majority in Malaysia are picked up with urinary tract infection within the first year of life.

The mainstay of treatment is to avoid urinary tract infections. This may include a long period of low dose antibiotics, circumcision for a boy child or minor endoscopic surgery (injection of deflux) to reduce the degree of reflux. Very rarely would bigger surgery such as re-implantation of the ureters be required with effective active prevention of urinary tract infection.

It’s imperative that early consult with a paediatric surgeon is made to plan optimal management form the offset to prevent any risk of kidney injury.

Constipation

Bowel and bladder function goes hand in hand. The rectum and colon sits just behind the bladder in a small pelvis of a child. Constipation causes a full colon or rectum, will push the bladder forward and can kink its outlet. This in turn will cause urine being stagnant and increase the risk of urinary tract infection. Bacteria that lives on the skin over the perineum is derived from the feces. With constipation, the stagnant feces in the colon, will “breed” more bacteria within. Often these are the more “aggressive” types of bacteria which may cause urinary tract infection when they travel up the urethra.

Regular bowel evacuation would require your child to consume good amount of water and fiber. Adequate water intake will in turn produce more urine to flush out the urinary system and not have stagnancy to encourage urinary tract infections. Children who has a tendency for constipation or urinary tract infections should take probiotics. The “good” bacteria not only help with the bowel motion but also have healthy non “aggressive” bacteria over the perineal skin.

My advice is to take good amounts of fruits and vegetables and fluid, mainly in the form of plain water, daily and supplements of probiotics to help with constipation and preventing urinary tract infection.

Poor bladder emptying

Children and adults should empty their bladders no longer than every 3 to 4 hourly if they are taking their adequate daily fluid requirement.  Some children are too busy playing that they forget to pass urine. Their bladder then begins to become enlarged can eventually give problems with the way it normally function, that is distend to a normal maximum size and empties out completely when required. The stagnant type of bladder then has a higher risk if urine infection. A child who was previously toilet trained and was dry both day and night and has wetting symptoms may have this as their cause of their wetting problem.

These kids will be required to go through a bladder retraining program as they can have issues with incontinence or urinary retention on the both ends of the spectrum. An early visit to their friendly pediatric surgeon is probably what they require.

Trauma

Injury can happen to any part of the urinary tract from the kidney down to the bladder and urethra. The kidneys are partially protected by the lower ribs and the chances of significant injuries to them are pretty low however even with an innocuous fall microscopic bleeding can be found in the urine sample though not obvious to the eyes, these are nothing to be worried about.

With a penetrating injury (puncture to the back or abdomen)or a high impact injury, it’s best to take your child to an emergency department and usually a CT scan is done to look for any intra-abdominal or intra thoracic injuries. Bladder injuries are again rare though it can be seen with lap-belt injury when a child is sat in a car or bus, with a full bladder. Urethral injuries are sometimes seen when children land on their perineum or when they fall and something hits them hard between their legs (straddle injury). This can injure the urethra. A child who is passing frank blood instead of urine need to be taken to the emergency department urgently. It is impossible to give all the possible scenarios of injury and when to take your child in to see the doctor. As a rule of thumb, a high impact injury or if your child has difficulties passing urine of if there is obvious blood coming out of the urethra are examples of possible symptoms for significant injury to your child’s urinary tract system. Otherwise take them to the hospital if you are worried in any way if they has some sort of injury.