Children with bladder and bowel dysfunction (BBD) and vesicoureteral reflux (VUR) have greater risk of developing recurrent urinary tract infections (UTIs) compared with children who have only one or neither of these disorders, according to a recent study.
“Data presented in this article provide a unique window into the poorly understood relationship between VUR, BBD, antimicrobial prophylaxis, and recurrent UTIs,” reported Nader Shaikh of the University of Pittsburgh, and his colleagues.
“Our results also underscore that, among toilet-trained children, prophylaxis was significantly more effective in children with both VUR and BBD than in any other subgroup of children,” they wrote (Pediatrics. 2015 Dec. 8. doi: 10.1542/peds.2015-2982). “This pattern suggests that children with both BBD and VUR have a substantial risk of recurrent UTIs and could potentially benefit the most from antimicrobial prophylaxis.”
The researchers analyzed data for 181 toilet-trained children aged younger than 6 years from two longitudinal studies. One study tracked children who had been diagnosed with VUR after a first or second UTI and were randomized to receive an antibiotic or placebo prophylactically. The other, parallel study, had enrolled children without VUR who did not receive antibiotic prophylaxis.
At enrollment and at the 1-year and 2-year follow-up visits, parents filled out the Dysfunctional Voiding Scoring System questionnaire used for providers to assess whether the child had BBD. The cut-off for having BBD was a score of at least 9 in boys and at least 6 in girls. The researchers assessed the children for constipation at baseline, 1 year, and 2 years based on the Paris Consensus on Childhood Constipation Terminology questionnaire.
At the study’s start, BBD was diagnosed in 54% of the children, all of whom were girls and 94% of whom reported daytime wetting, constipation, or withholding maneuvers, such as crossing legs, squatting, or “dancing” around. In addition, 39% reported frequent painful defecation, 22% met criteria for constipation, and 8% had fewer than three bowel movements per week over the previous 8 weeks.
Among the toilet-trained children with VUR, 57% had BBD, compared with 46% of the children without VUR (P = .15). Presence of BBD did not predict grades of VUR, and no specific symptoms of BBD or constipation correlated with VUR.
Just over half (51%) of the children with BBD and VUR had recurrent UTIs if not taking prophylaxic antibiotics. Yet only 20% of children with only VUR, 35% of children with BBD alone, and 32% of children without VUR or BBD developed recurrent UTIs when not taking antimicrobial prophylaxis.
Among children with VUR and taking antibiotics, BBD did not predict recurrent UTIs, which occurred for 18% of those with BBD and for 25% of those without.
Children with both VUR and BBD but without antimicrobial prophylaxis were more than three times more likely to have recurrent UTIs than were children with only VUR (hazard ratio, 3.49), and nearly six times more likely (HR, 5.71) after adjustment for age, sex, race, and clinic site.
No evidence of causation between BBD and VUR appeared, and the former was not significantly associated with renal scarring.
Screening for at least one of these conditions (BBD or VUR) seems justifiable on the basis of these data, but VUR screening is more invasive and VUR treatment has greater risk of harm than treatment of BBD, the authors pointed out.
“Thus, one approach would be to routinely screen all toilet-trained children with UTI for BBD and to treat BBD in those who screen positive,” they wrote. Only additional research can determine if this is the most effective strategy.
The National Institute of Diabetes and Digestive and Kidney Diseases funded the research. The authors reported no disclosures.