Ultrasonography in the Radiologic Evaluation of Children With Urinary Tract

Infection
Uri Alon, Menucha Pery, Giora Davidai and Moshe Berant
Pediatrics 1986;78;58-64

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1986 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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 Ultrasonography in the Radiologic Evaluation of
Children With Urinary Tract Infection

Un Alon, MD, Menucha Pery, MD, Giora Davidai, MD, and

Moshe Berant, MD

From the Section of Pediatric Nephrology and the Departments of Diagnostic Radiology
and Pediatrics, Ramban Medical Center, and Faculty of Medicine, Technion-lsrael
Institute of Technology, Haifa, Israel

ABSTRACT. A prospective blind study comparing the also indicated. For hospitalized patients, especially young
findings of ultrasonography, intravenous pyelography, children, ultrasonography can be used as the early screen-
and voiding cystourethrography was conducted on 81 ing procedure, within two to four days after the diagnosis
patients to examine the place of ultrasonography in the of urinary tract infection. If the results are normal, cys-
initial radiologic evaluation of children with urinary tract tourethrography can follow after 4 to 6 weeks; if abnor-
infection. The patients’ mean age was 4.8 years; 15 were mal, cystourethrography can be performed after ten to 14
male. Forty-eight were inpatients (mean age, 3.2 years) days. Here, too, intravenous pyelography is needed only
and 33 were outpatients (mean age, 7.2 years). In 29 when ultrasonography and/or cystourethrography results
patients (35.8%) abnormality of the urinary system was are abnormal. Pediatrics 1986;78:58-64; ultrasonography,
detected by one or more of the three imaging procedures; radiologic evaluation, urinary tract infection.
21 were inpatients and eight were outpatients. The most
frequent finding was vesicoureteral reflux, occurring in
62. 1 % of the pathologic cases. The findings at ultraso-
nography correlated well with those of intravenous pye- Routine radiologic evaluation of children with
lography in 73 of the 81 studies (90.1%), but they failed urinary tract infection includes intravenous pyelog-
to demonstrate double collecting systems and several of raphy (IVP) and voiding cystourethrography, aim-
the minor changes. However, ultrasonography in combi- ing to detect patients at risk for renal damage,
nation with cystourethrography identified all patients
namely, those with obstructive uropathy or vesi-
who had abnormal urinary systems, except for two chil-
dren with negligible findings. Moreover, ultrasonography coureteral reflux.’3 In recent years, with the in-
and cystourethrography together identified all 1 1 pa- creasing utilization of kidney ultrasonography and
tients, nine of them inpatients, in whom surgical treat- the growing evidence of its usefulness in children,4’5
ment was indicated. It is concluded that ultrasonography the question arose as to its possible value in the
can successfully replace intravenous pyelography as a
radiologic evaluation of children with urinary tract
screening imaging procedure for the urinary system, but
because of the superiority of intravenous pyelography in infection. Although a few uncontrolled studies have
the detection of some types of lesions, intravenous pye- addressed this question,3’6 it was stated in a recent
lography will be required whenever ultrasonography or editorial7 that “at this time, however, there is in-
cystourethrography results are abnormal. Accordingly, sufficient experience to recommend sonography as
and in view of the differences in the frequency and a routine procedure.” Others8 have stressed the
severity of pathologic findings between outpatients and
need for a prospective study evaluating the useful-
hospitalized patients, the following protocol is suggested
for the radiologic evaluation of children with urinary ness and reliability of ultrasonography as a diag-
tract infection: For outpatients, cystourethrography can nostic tool in children with urinary tract infection.
be performed 4 to 6 weeks after cessation of antibiotic The present study was undertaken for better clan-
therapy. If the study is normal, ultrasonography can be
fication of the place of ultrasonography in the
done; if this is also normal, no further radiologic workup
is needed. Only when cystourethrography or ultrasonog- radiologic workup of children with urinary tract
raphy findings are abnormal is intravenous pyelography infection, by comparison of the findings of IVP,
voiding cystounethrography, and ultrasonography
Received for publication July 25, 1985; accepted Oct 24, 1985. in a prospective blind study of 81 patients.
Reprint requests to (U-A.) Section of Pediatric Nephrology,
Department of Pediatrics, Ramban Medical Center, Haifa 35254, MATERIALS AND METHODS
Israel.
PEDIATRICS (ISSN 0031 4005). Copyright © 1986 by the All children hospitalized or seen at the outpatient
American Academy of Pediatrics. clinic between June 1, 1984, and April 15, 1985,

58 PEDIATRICS Vol. 78 No. 1 July 1986

Downloaded from www.pediatrics.org by on September 10, 2010
because of symptomatic urinary tract infection and and at ten minutes; if necessary, prone radiographs
in whom radiologic evaluation was indicated were were added. Additional oblique and postvoiding ra-
included in the study. Diagnosis of urinary tract diographs or tomography were used when indicated.
infection was established by a urine culture growing Voiding cystourethrography was performed in
i05 or more bacterial colonies per milliliter, if ob- children after they had emptied their bladders; in-
tamed by catheterization, or twice positive cultures fants voided during catheterization of the urethra.
obtained by midstream catch, or a positive bacterial The bladder was filled with 30% Urographin under
growth from urine obtained by suprapubic aspira- fluoroscopic visualization until full capacity. If pas-
lion.9 Height, weight, BP, and serum creatinine sive reflux was observed during filling, a radiograph
concentration were recorded for all patients.7 mdi- was obtained. The maximally distended bladder
cations for radiologic evaluation were as follows: was radiographed routinely. After the catheter was
first-documented urinary tract infection in male removed, the patient would begin to void. If reflux
patients, first-documented urinary tract infection was noted during voiding, a radiograph was taken.
in female patients younger than 5 years of age, first If not, a postvoiding radiograph including the kid-
infection presenting as severe clinical pyelonephni- neys, ureters, bladder, and urethral areas was ob-
tis in older girls, and second infection (or total tamed. Vesicoureteral reflux was graded from 1 to
number) in girls older than 5 years of age.91’ 5, based on the system adopted by the Internationl
Renal ultrasonography was performed first: in Reflux Study Committee.’4
outpatients, on the first visit to the clinic, and in Because of technical inadequacy, IVP had to be
inpatients, between the second and fourth day of repeated in two patients and renal ultrasound in
hospitalization. The procedure was carried out with one. Renal ultrasonography, IVP, and voiding cys-
a gray-scale Picker static scanner with 3.5-MHz tourethrography were performed and interpreted
and 5.0-MHz transducers, and an Aloka real-time separately by the same pediatric radiologist (M.P.)
sector scanner with a 5.0-MHz transducer. Longi- without knowledge of the patient’s details, and all
tudinal supine and prone scans and transverse data were kept coded until the end of the study.
prone scans were performed in order to evaluate
RESULTS
position, size, and anatomy of the kidneys. The
kidneys’ lengths were measured in longitudinal Eighty-one children between the ages of 2 weeks
prone view.12’13 For the detection of renal scars the and 12 years (mean, 4.8 years) were included in the
parenchymal width was measured along the whole study. Thirty-three were outpatients (mean age, 7.2
length of each kidney and compared bilaterally. In years) and 48 were inpatients (mean age, 3.2 years).
addition, serial longitudinal scans with 0.5- to 1.0- Male to female ratio was similar in both groups
cm intervals were carried out, with accentuation on (1:5.3). Height, weight, BP, and serum creatinine
the central echogenic pattern that represents the concentration were normal in all patients, except
kidney sinus and calyces, to detect double collecting for two who eventually were found to have chronic
systems. renal failure.
In most cases IVP and voiding cystourethrogra- No pathologic findings were detected by any of
phy were performed 4 to 6 weeks after completion the three imaging procedures in 52 children
of antibiotic therapy.7 During that interval the chil- (64.2%). Of the 33 outpatients, pathology was dem-
dren were kept on continuous low-dose chemopro- onstrated in eight (24.2%), whereas of the 48 in-
phylaxis, and urine cultures were obtained 2 weeks patients abnormality was seen in 21 (43.8%). The
before and again on the day of voiding cystoure- radiologic findings and the subsequent manage-
thrography to ensure that the patient was free from ment are presented in detail in Tables 1 and 2 and
infection at the time of voiding cystourethrogra- are summarized in Table 3. Of the 29 cases with
phy.2 For hospitalized children in whom renal ul- abnormal urinary system, vesicoureteral reflux was
trasonography revealed a major pathology for which demonstrated in 18, other lower urinary tract pa-
immediate surgical intervention would be indicated, thologies in four, unilateral or bilateral hydrone-
IVP and voiding cystourethrography were per- phrosis in 11, and partial or complete double col-
formed earlier, usually after completing a ten- to lecting systems in six. In patients 6 and 17 a uni-
14-day course of full-dose antibiotic therapy. lateral contracted kidney was detected, in patient
Intravenous pyelography was preceded by plain 25 both kidneys were contracted, and in patient 11
abdominal and pelvic radiographs. Sixty percent one kidney was multicystic dysplastic. Patients 8,
Urographin was injected intravenously, 1 mL/kg of 14, and 21 had minor changes-a calyceal cyst, a
body weight in children and 2 to 3 mL/kg of body single clubbed calyx, and mild dilation with club-
weight in small infants. Supine radiographs of the bing of the collecting system of the lower pole,
kidneys and bladder were obtained at five minutes respectively.

ARTICLES 59
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 Renal ultrasonography and IVP correlated well
11)
. in 73 of the 81 patients (90.1% including
), all of the
a
fi 0 patients with normal kidneys and those with hy-
0
a
a dronephrosis and contracted kidneys (Table 3).
a? - aa
.)-- -- a
00 aoo oo One-by-one analysis of the eight patients in whom
8 .‘

- #{149}E
a 5)5) - a)a) 5)5) there was discrepancy between the two diagnostic
modes indicates the following (Tables 1 and 2): In
-
I patients 2, 14, and 21 ultrasonography failed to
5)
. 5)
detect findings that were noted on IVP; in all three
cases voiding cystourethrography was abnormal. In
patients 18 and 24 a double collecting system was
-a
not detected by ultrasonography. However, in both
a.
a patients ultrasonography detected the accompany-
ing hydronephrosis, which was also shown by IVP.
. a
c___ a A unilateral double collecting system without ob-
>‘-E struction or reflux in patient 7 and a calyceal cyst

0
i “t
0 aaz
5?5)’ zz 00
I-’” in patient 8 were diagnosed only by IVP, whereas
bL in patient 1 1 only ultrasonography disclosed the
a a
.-
0 cystic nature of the kidney not visualized on IVP.
0 a)5?
C.) Thus, except for patients 7 and 8, voiding cysto-
:;l-
a urethrography and ultrasonography in combination
-)
0
a
could identify all children with an abnormal urinary
‘C ) C
system.
, 0

>, C- a I-
Eleven patients, two of whom were outpatients,
a
a a 0 .,
underwent surgical treatment (Table 3). Five of
‘C , - a
_c them needed immediate intervention; all were in-
:‘
a? patients and younger than 15 months. Without
Cl)
‘ E
I.,
A I.,I5)
) exception, ultrasonography combined with voiding
00 ooa a
0 z;: 0 zz- : cystourethrography disclosed urinary system pa-
0
a #{176}a -a
4.#{232}
thology in all 1 1 operated children, and ultrasonog-
0 5?
raphy was grossly abnormal in all five children in
:_ whom urgent surgical treatment was indicated.
, Cl) 0I-a’ 0-0a
a-0
0.
DISCUSSION

Intravenous pyelography has become established

-a
5) as an important tool in the investigation of patients
N

a
‘C
with urinary tract infection, but its drawbacks in-
a) 5)
C.)
a dude invasiveness, radiation exposure, allergic re-
5)
0, actions, and radiocontrast-induced acute renal fail-
Cl)
Cl) ure.’5’16 On the other hand, ultrasonography of the
a. kidneys does not carry such hazards and has the
a a
aa a -- --
88 advantages of being relatively lower in cost, easier
0
a 1-
0 00 0 0 a 0 0 to perform, and able to be repeated as many times
a
a
I-
zz A ZZ..rj EZZ
as needed and to enable simultaneous demonstra-
.
Cl)
Cl)
a
‘C
tion of other abdominal organs. In addition, tech-
0
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nical adequacy does not depend on kidney func-
a. C- tion.4’5”7”8 However, renal ultrasonography may be
a)Cl)
as)
oa
‘Co
-Cl) inferior to IVP in imaging some details, such as
8-’ ureters and small scars, and demands an experi-
Cl)
enced radiologist for adequate interpretation.2’3’6
a)Lt3 cl)cC
Therefore, it appears to be of clinical importance
‘-4
‘-4
cClCl) 0)CI to assess whether and to what extent ultrasonog-
raphy can replace the classic role of IVP in the
a
routine radiologic evaluation of children with un-
.5 ci c’ LOCD t-c0
nary tract infection.
a.
In the present study we found that ultrasonog-

60 ULTRASONOGRAPHY IN URINARY TRACT INFECTION

Downloaded from www.pediatrics.org by on September 10, 2010
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ARTICLES 61
Downloaded from www.pediatrics.org by on September 10, 2010
. raphy can effectively replace IVP as a screening
> -
a. - C1t- © C’) c.-: .
a imaging procedure of the upper urinary tract. U!-
a #{176} - Ca C’) ‘ ‘-4 ci ‘-4 trasonographic findings were similar to IVP find-
- F- - -4

a) 0)
‘4 + +
4+
+
ings
with innormal
90.1% of 81
kidneys, cases, including
hydronephrosis, all and
patientscon-

a 4-,.
0 C” + + + tracted kidneys (Table 3). Of the remaining eight
a
a)
C- .4-’. cases, ultrasound was superior to IVP in one child
a
‘C
+ + + + with chronic renal failure and multicystic displastic
4) C-.
j + - kidney, confirming the findings of Kangarloo et aL6

- gi + + + + In the other seven cases, ultrasonography was in-

a.
a
. a
a.
ferior to IVP in the detection of the urinary tract
5 ; #{247}+ + + I + a anomalies, confirming the superiority of IVP in the
0
a C’) ‘C
0ca + a diagnosis of minor anatomic details.2’6 However,
a -
4)‘C 4
Ci + a except for patients 7 and 8, whose negligible find-
a
ings did not necessitate any active approach,3”9’2#{176}
+ +1 +1 -a
a a
a
ultrasonography combined with voiding cystoure-
-a
a) Z
d ,-; thrography could detect all of the 27 patients with

-
4)

: ci
-

a
clinically
only voiding
significant urinary
cystourethrography
tract anomalies.
was abnormal;
In 11,
in
C I +
4+ -4 ten, both voiding cystourethrography and ultraso-
a a
4)

0 r- + + + + nography were abnormal; and in the other six, only

C.)

+
ultrasonography was abnormal (Table 3).
a. - Mason3 and Kangarloo et al,6 in their retrospec-

E-’
: a
C.) &t)

Z +
#{247}
+ I
+ c tive
that
studies, reached
ultrasonography
similar conclusions,
can replace
namely,
IVP as a screen-
++ a-
‘C a ing procedure. Intravenous pyelography is never-
a S , theless indicated whenever ultrasonography or
+ ++

a 4-,.
-I
.
a? voiding cystourethrography
mal because IVP can also are foundkidneyto befunction
reflect abnor-
: #{247}++
a
a)
o + and may be superior in diagnosing some of the
anomalies and the fine details, such as double col-
‘C I 0
=a
-a ;a)H+
II ++ a.
a?
‘C.) 8 lecting systems and scars. Mason3 proposes starting
0 I a
0)
ci
I + S
Oa -a
aa
the nadiologic evaluation of children with urinary
.8 I + I a tract infection with voiding cystourethrography,
a ao whereas the other authors6 recommend beginning
CO + + a a with ultrasonography. Analysis of their studies
- Lf) + shows that they address, in fact, two different pa-
. . I
C.) tient populations. Whereas Mason3 examined out-
.8 +
a. patients who were referred for radiologic evalua-
C’) + + + !- tion, Kangarloo et a!6 reviewed data derived mainly
a
a
I I 2 from inpatients and complicated cases that were
Cl) a?5
bC ‘C-.
a _
+
n
oa
referred to their medical center. Indeed, the fre-
‘8 quencies of abnormal radiologic findings of approx-
.8 - I ‘C.)
C. L 0 imately 23% among the outpatients3 and 49%
C.)

-a aa.
-.- : . 00
;C. ;;C.- _, 00 - bl) tients
among inthe
figures of our inpatients6
22.4% presentin outpatients
series.
are similar
In and
addition,
to 43.8%
the respective
although
in inpa-
‘C Cl)
‘
. a8 : 0 ‘ll 9 Mason does not provide exact details, comparison
) 8 .,- a; a a? of the two aforementioned retrospective studies
a a a
8 2 I : ‘ a? a a shows that the severity of the abnormal findings
8 a 8a? 4)
: was greater among the inpatients. This is also true
no ‘Ca?cC)
a?
.8bl) a 0
CI) - a -a a C- bl) a a for the present study, in which nine of the 11
a
.a -a2 a ‘Crn,
a?
aa
a a
oa
n patients who required surgical treatment, as well as
C’5 89a
: . all five in whom immediate surgical intervention
Iii 1 a a a Q a was indicated, were inpatients. Therefore, our find-
;;; -2 0
-a 8
<a a?
I- a 0 0 0 Cl) .,- ..-‘ ings combined with those of the two other studies3’6

62 ULTRASONOGRAPHY IN URINARY TRACT INFECTION

Downloaded from www.pediatrics.org by on September 10, 2010
support Ben-Ami’s suggestion2 that outpatients and cystounethrography is abnormal, then IVP is mdi-
hospitalized children deserve a different radiologic cated. When ultrasonography in the inpatient is
strategy. abnormal, then voiding cystourethrography and
Based on the cumulative data and recommenda- IVP should be performed much earlier, once the
tions from the literature2’3’6 and from the present acute infection has subsided.2
study, we propose an algorithm for the radiologic With this algorithm, according to our data and
evaluation of children with urinary tract infection those of Mason,3 about 75% of the outpatients will
(Figure). The investigation of outpatients should have to undergo only voiding cystourethrography
start with voiding cystourethrography, which can and ultrasonography; about 20% will need voiding
disclose the majority of 21 This pro- cystourethrography and IVP, and only less than 5%
cedure should preferably be performed 4 to 6 weeks will have to be examined by all three studies. Thus,
after completion of the initial antimicrobial thera- when this scheme is applied, three quarters of the
peutic course, in order to avoid radiologic findings outpatients will be spared IVP, and less than 5%
attributable to the active inflammation.2’7 If voiding will have to be examined by all three imaging pro-
cystourethrography is normal, the studies proceed cedures. By this approach, the need for IVP in
with ultrasonography; if this investigation is also inpatients will be reduced by more than 50%.
normal, no further radiologic workup is necessary. It should be emphasized that all current works
In the event that voiding cystourethrography is deal with the initial radiologic evaluation of chil-
abnormal, IVP is indicated and ultrasonography is dren with urinary tract infection; therefore, not
not necessary. Intravenous pyelography is also in- enough data are available for comparing IVP vs
dicated when ultrasonography is found to be abnor- ultrasonography in the long-term radiologic follow-
mal. up of these patients. Wyly et al’#{176}
have recently
For hospitalized children, who are usually demonstrated the efficacy of ultrasonography in the
younger and more severely ill, our suggestion is in radiologic investigation of complicated duplex kid-
agreement with the recommendations of Ben-Ami2 neys, and dell’Agnola et a117 reported on the useful-
and Kangarloo et al,6 ie, to start with an early ness of ultrasonography in the postoperative man-
ultrasonography as a screening procedure when di- agement of children with hydronephnosis. It is pos-
agnosing those patients who require immediate sun- sible that further experience will provide better data
gical management. If ultrasonography is normal, to assess the reliability of ultrasonography as a
voiding cystourethrography is to be scheduled as in substitute for JVP in these and other pathologic
outpatients. In case voiding cystourethrography is conditions.2’6’8
also found to be normal, no further radiologic stud- In summary, the present prospective blind study
ies are required. On the other hand, if voiding confirms the observation that ultrasonography can

NORMAL

NORMAl NORMAL

, -C

ASNORMAL [ VCUGJ._:_.4OUTpATIENT1
, / WEEKS

“ABNORMAL

: v P1

OTHER INVESTIGATIONS,
MEDICAL OR SURGICAL
TREATMENT

Figure. Algorithm for initial radiologic evaluation of patients by dashed arrows. Abbreviations are: IVP, intra-
children with urinary tract infection. Protocol for inpa- venous pyelography; US, renal ultrasonography; VCUG,
tients is described by solid arrows and protocol for out- voiding cystourethrography.

ARTICLES 63
Downloaded from www.pediatrics.org by on September 10, 2010
successfully replace IVP as a screening imaging infection in infants and children evaluated by ultrasound.
Radiology 1985;154:367-373
procedure in the initial radiologic evaluation of
7. Hellerstein 5, Wald ER, Winberg J, et al: Consensus: Roent-
children with urinary tract infection. In expeni- genographic evaluation of children with urinary tract infec-
enced hands, ultrasonography can obviate the need tions. Pediatr Infect Di,s 1984;3:291-293
8. Redman JF, Seibert JJ: The role of excretory urography in
for IVP in the normal cases, but IVP would still be
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64 ULTRASONOGRAPHY IN URINARY TRACT INFECTION

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 Ultrasonography in the Radiologic Evaluation of Children With Urinary Tract
Infection
Uri Alon, Menucha Pery, Giora Davidai and Moshe Berant
Pediatrics 1986;78;58-64
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