Pediatric UTI Imaging

Question 1

Clinical Vignette: You are consulted regarding a 4-month-old male who has a positive ultrasound following a febrile UTI. You are considering further imaging modalities. Which guideline recommends conducting a Voiding Cystourethrogram (VCUG) in this case?

Multiple-Choice Options:
A) RCH
B) NICE
C) TDA
D) AAP

Answer 1

Correct Answer: A) RCH

Explanation: According to the table, the RCH guidelines recommend Voiding Cystourethrogram if boys are under 6 months and/or have a positive ultrasonography.

Memory Tool: RCH = Really Caring for Him; Boys under 6 months get a VCUG.

Reference Citation: Data from La Scola C, De Mutiis C, Hewitt IK, et al.: Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation. Pediatrics 131:e665–671, 2013.

Rationale for Importance: Knowing specific guidelines for imaging in pediatric UTIs is crucial for optimal patient care and can significantly affect treatment plans.

Question 2

Clinical Vignette: A 10-month-old girl presents with atypical UTI symptoms. You wonder which imaging modality is recommended by the NICE guidelines in this case.

Multiple-Choice Options:
A) Ultrasound
B) Voiding Cystourethrogram
C) Late DMSA Scan
D) No Imaging

Answer 2

Correct Answer: A) Ultrasound

Explanation: The NICE guidelines recommend an ultrasound for patients over 6 months if they have an atypical UTI.

Memory Tool: NICE to be Atypical; Atypical UTIs in children over 6 months warrant an Ultrasound.

Reference Citation: Data from La Scola C, De Mutiis C, Hewitt IK, et al.: Different guidelines for imaging after first UTI in febrile infants: yield, cost, and radiation. Pediatrics 131:e665–671, 2013.

Rationale for Importance: Understanding the criteria for atypical UTIs and the appropriate imaging modalities can lead to timely and accurate diagnoses, avoiding complications.

Question 3

Clinical Vignette: You are treating a 3-year-old child with a history of septicemia and poor urine flow. According to the ISPN guidelines, what imaging is recommended?

Answer Choices:
A) Ultrasound only
B) Voiding Cystourethrogram and Late DMSA Scan
C) Voiding Cystourethrogram only
D) Late DMSA Scan only

Answer 3

Correct Answer: B) Voiding Cystourethrogram and Late DMSA Scan

Explanation: The ISPN guidelines recommend both Voiding Cystourethrogram and Late DMSA Scan for children with risk factors, such as a history of septicemia and poor urine flow.
Memory Tool: ISPN = I Seriously Prefer Not (to ignore risk factors); so, do both!
Specific Reference Citation: Table 25.1, Data from La Scola C, et al., Pediatrics 131:e665–671, 2013
Rationale: Tailoring imaging to individual risk factors can improve diagnostic accuracy and outcomes.

Question 4

Clinical Vignette: A 4-year-old girl presents with recurrent urinary tract infections. A voiding cystourethrogram is performed, revealing reflux into the renal pelvis and calyces without dilation.
Multiple Choice Options:

A) Grade 1 Vesicoureteral Reflux
B) Grade 2 Vesicoureteral Reflux
C) Grade 3 Vesicoureteral Reflux
D) Grade 4 Vesicoureteral Reflux

Answer 4

Correct Answer: B) Grade 2 Vesicoureteral Reflux
Explanation: According to Table 29.3, Grade 2 Vesicoureteral Reflux is described as reflux “Into the pelvis and calyces without dilation,” which matches the patient’s presentation.
Memory Tool: “Two into the Pool, but no Balloon” – Grade 2 goes into the pelvis and calyces but doesn’t dilate them.
Reference Citation: Table 29.3
Rationale for Importance: Correctly grading vesicoureteral reflux aids in the appropriate management and treatment of recurrent UTIs in pediatric patients.

Question 5

Clinical Vignette: An 8-year-old boy has been diagnosed with vesicoureteral reflux following a UTI. The diagnosis reveals mild to moderate dilation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices.
Multiple Choice Options:

A) Grade 1 Vesicoureteral Reflux
B) Grade 2 Vesicoureteral Reflux
C) Grade 3 Vesicoureteral Reflux
D) Grade 4 Vesicoureteral Reflux

Answer 5

Correct Answer: C) Grade 3 Vesicoureteral Reflux
Explanation: In Table 29.3, Grade 3 Vesicoureteral Reflux is characterized by “Mild to moderate dilation of the ureter, renal pelvis, and calyces with minimal blunting of the fornices,” fitting the patient’s condition.
Memory Tool: “Three’s a Crowd” - Grade 3 involves dilation, making the ureter and renal pelvis more “crowded.”
Reference Citation: Table 29.3
Rationale for Importance: Identifying the severity helps in tailoring the treatment plan, particularly in children where ongoing monitoring is essential.

Question 6

Clinical Vignette: A 2-year-old boy is brought to the ER for a severe UTI. Imaging shows gross dilation of the ureter, pelvis, and calyces with loss of papillary impressions and ureteral tortuosity.
Multiple Choice Options:

A) Grade 3 Vesicoureteral Reflux
B) Grade 4 Vesicoureteral Reflux
C) Grade 5 Vesicoureteral Reflux
D) Grade 1 Vesicoureteral Reflux

Answer 6

Correct Answer: C) Grade 5 Vesicoureteral Reflux
Explanation: According to Table 29.3, Grade 5 Vesicoureteral Reflux involves “Gross dilation of the ureter, pelvis, and calyces; loss of papillary impressions; and ureteral tortuosity,” which aligns with this case.
Memory Tool: “High Five for Worst Case” – Grade 5 is the most severe.
Reference Citation: Table 29.3
Rationale for Importance: Severe grades of vesicoureteral reflux often require surgical intervention; thus, accurate grading is crucial.

Question 7

Clinical Vignette:
A newborn is diagnosed with posterior urethral valves. You’re concerned about the potential effects on other organs.

Question:
What is the natural history of pulmonary hypoplasia caused by posterior urethral valves in newborns?

Options:
A. Usually improves with age
B. May be fatal in newborns
C. Leads to progressive respiratory failure
D. Limited data on long-term natural history of survivors

Answer 7

Correct Answer:
B. May be fatal in newborns

Explanation:
The natural history of pulmonary hypoplasia caused by posterior urethral valves may be fatal in newborns. This is especially important to note when managing newborns with the condition.

Memory Tool:
Think “New-B Fatal” to remember that in newborns, the condition may be fatal.

Reference Citation:
(Table 33.1, Paragraph on Lung Effects)

Rationale:
This question is crucial for understanding the immediate life-threatening consequences of posterior urethral valves in newborns.

Question 8

Correct Answer:
B. May be fatal in newborns

Explanation:
The natural history of pulmonary hypoplasia caused by posterior urethral valves may be fatal in newborns. This is especially important to note when managing newborns with the condition.

Memory Tool:
Think “New-B Fatal” to remember that in newborns, the condition may be fatal.

Reference Citation:
(Table 33.1, Paragraph on Lung Effects)

Rationale:
This question is crucial for understanding the immediate life-threatening consequences of posterior urethral valves in newborns.

Answer 8

Correct Answer:
B. Obstructive uropathy

Explanation:
Obstructive uropathy is generally reversible, with renal insufficiency usually improving with initial treatment. However, it can recur with bladder dysfunction.

Memory Tool:
“O-B Can Be Over” - Obstructive uropathy can be overcome with treatment.

Reference Citation:
(Table 33.1, Paragraph on Kidney Effects)

Rationale:
Understanding reversible and irreversible kidney damages aids in making informed treatment decisions for posterior urethral valve patients.

Question 9

Clinical Vignette:
A 40-year-old man is experiencing urinary incontinence and has a history of posterior urethral valves.

Question:
How would you describe the natural history of bladder problems in patients with posterior urethral valves?

Options:
A. Sporadic and unpredictable
B. Usually improve with age
C. Bladder problems are lifelong and change with age and management
D. Limited data on long-term natural history

Answer 9

Correct Answer:
C. Bladder problems are lifelong and change with age and management

Explanation:
Bladder problems in patients with posterior urethral valves are lifelong and can change with age and management.

Memory Tool:
“BL-ifeLong” to remember that bladder issues are lifelong.

Reference Citation:
(Table 33.1, Paragraph on Bladder Effects)

Rationale:
Managing bladder dysfunction is essential for improving the quality of life in these patients.

Question 10

Clinical Vignette:
A 50-year-old male with a history of posterior urethral valves is experiencing frequent thirst and urination.

Question:
Which kidney damage due to posterior urethral valves is likely causing his symptoms?

Options:
A. Glomerular injury
B. Obstructive uropathy
C. Dysplasia
D. Tubular injury

Answer 10

Correct Answer:
D. Tubular injury

Explanation:
Tubular injury leads to an inability to limit sodium and water loss, which may cause symptoms like frequent thirst and urination. This tends to be progressive with age and can result in nephrogenic diabetes insipidus.

Memory Tool:
Think “Thirsty Tubules” to remember that tubular injury can lead to frequent thirst and urination.

Reference Citation:
(Table 33.1, Paragraph on Kidney Effects)

Rationale:
Recognizing the late-stage symptoms of tubular injury is crucial for long-term management and can potentially prevent nephrogenic diabetes insipidus.

Question 11

Clinical Vignette:
A 20-year-old male, with a history of posterior urethral valves, presents with recurring episodes of urinary tract infections. Imaging shows chronic hydronephrosis.

Question:
What is the natural history of ureteral damage in patients with posterior urethral valves?

Options:
A. Usually resolves spontaneously
B. Lifelong, with no changes over time
C. Many will improve initially, but most have chronic hydronephrosis
D. Will progressively worsen with age

Answer 11

Correct Answer:
C. Many will improve initially, but most have chronic hydronephrosis

Explanation:
Poor contractility and inability to coapt and transport urine are common ureteral issues in patients with posterior urethral valves. Many patients will see initial improvement, but most will develop chronic hydronephrosis over time.

Memory Tool:
Think “Up then Down Ureters” to remember that ureters may improve initially but are likely to result in chronic issues.

Reference Citation:
(Table 33.1, Paragraph on Ureter Effects)

Rationale:
This question addresses the natural history of ureteral damage which is essential for long-term management and can influence treatment options.

Question 12

Clinical Vignette:
A 10-year-old boy, known to have posterior urethral valves, is showing poor growth and has developed hypertension.

Question:
What type of renal damage is most likely responsible for these symptoms?

Options:
A. Glomerular injury
B. Obstructive uropathy
C. Dysplasia
D. Tubular injury

Answer 12

Correct Answer:
C. Dysplasia

Explanation:
Dysplasia leads to irreversible renal insufficiency and limits growth. It eventually causes progressive renal failure and hypertension.

Memory Tool:
“Disastrous Dysplasia” to remember that dysplasia leads to a host of irreversible issues like poor growth and hypertension.

Reference Citation:
(Table 33.1, Paragraph on Kidney Effects)

Rationale:
Understanding the irreversible nature of dysplasia can guide medical professionals toward more aggressive management strategies for such patients.

Question 13

Clinical Vignette:
A 30-year-old male with a history of posterior urethral valves complains of frequent accidents and difficulty in sensing when his bladder is full.

Question:
Which bladder issue is most likely contributing to his symptoms?

Options:
A. Hypercontractility
B. Low compliance
C. Poor sensation
D. Myogenic failure

Answer 13

Correct Answer:
C. Poor sensation

Explanation:
Poor sensation in the bladder is one of the effects of posterior urethral valves, leading to incontinence and difficulty in recognizing a full bladder.

Memory Tool:
“Pee-Sensation-Poor” to remember that poor sensation can cause frequent accidents.

Reference Citation:
(Table 33.1, Paragraph on Bladder Effects)

Rationale:
Understanding the specific issues affecting the bladder can guide targeted management strategies for symptom relief.

Question 14

Clinical Vignette:
A 2-year-old boy previously diagnosed with posterior urethral valves and treated for obstructive uropathy is experiencing renal insufficiency again.

Question:
What is a likely cause of the recurrence of his renal insufficiency?

Options:
A. Non-compliance with medications
B. Natural progression of dysplasia
C. Recurrence due to bladder dysfunction
D. Development of glomerular injury

Answer 14

Correct Answer:
C. Recurrence due to bladder dysfunction

Explanation:
Obstructive uropathy usually improves with initial treatment but can recur with bladder dysfunction, thereby causing renal insufficiency again.

Memory Tool:
“Back with the Bladder” to remember that recurrence is often linked to bladder dysfunction.

Reference Citation:
(Table 33.1, Paragraph on Kidney Effects)

Rationale:
Knowing the potential causes for recurrence can help in early intervention and modification of treatment plans.

Question 15

Clinical Vignette:
A 12-year-old boy with a history of posterior urethral valves is experiencing progressive renal failure and hypertension.

Question:
Which type of kidney damage in posterior urethral valves is associated with progressive renal failure and hypertension?

Options:
A. Glomerular injury
B. Obstructive uropathy
C. Dysplasia
D. Tubular injury

Answer 15

Correct Answer:
C. Dysplasia

Explanation:
Dysplasia results in irreversible renal insufficiency, leading to progressive renal failure and hypertension.

Memory Tool:
“Dreadful Dysplasia” to remember its severe, progressive outcomes.

Reference Citation:
(Table 33.1, Paragraph on Kidney Effects)

Rationale:
Identifying dysplasia as a cause can alert clinicians to prepare for more aggressive, long-term management options.

Question 16

Clinical Vignette:
A 5-year-old child is brought into the clinic with incontinence issues. An MRI reveals sacral agenesis.

Multiple-Choice Options:
A. Extensive pelvic surgery
B. Transverse myelitis
C. Sacral agenesis
D. Central nervous system insults

Answer 16

Correct Answer:
C. Sacral agenesis

Explanation:
Sacral agenesis is a congenital cause of neuromuscular dysfunction of the lower urinary tract as listed in Table 34.1. Extensive pelvic surgery, Transverse myelitis, and Central nervous system insults are acquired causes.

Memory Tool:
Remember “Sacral agenesis = Sits at birth” to recall it is a congenital issue.

Specific Reference Citation:
Table 34.1

Rationale for the Question:
This question highlights the distinction between congenital and acquired causes, which is crucial for diagnosis and treatment planning.

Question 17

Clinical Vignette:
A 60-year-old male patient with a history of pelvic surgery reports urinary retention.

Multiple-Choice Options:
A. Occult forms of neural tube defect
B. Transverse myelitis
C. Extensive pelvic surgery
D. Sacral agenesis

Answer 17

Correct Answer:
C. Extensive pelvic surgery

Explanation:
Extensive pelvic surgery is an acquired cause of neuromuscular dysfunction of the lower urinary tract, as stated in Table 34.1. Occult forms of neural tube defect and Sacral agenesis are congenital causes, while Transverse myelitis is an acquired spinal cord insult.

Memory Tool:
Think “Pelvic Puzzles” to remember that pelvic surgeries can create complexities in lower urinary function.

Specific Reference Citation:
Table 34.1

Rationale for the Question:
This question focuses on acquired causes of neuromuscular dysfunction, a topic that may come up frequently in adult patients.

Question 18

Clinical Vignette:
A 50-year-old woman presents with new-onset urinary incontinence. A CT scan reveals a brain tumor.

Multiple-Choice Options:
A. Conditions of the brain (tumors, infarcts, encephalopathies)
B. Anorectal malformations
C. Cerebral palsy
D. Neural tube defect

Answer 18

Correct Answer:
A. Conditions of the brain (tumors, infarcts, encephalopathies)

Explanation:
Conditions of the brain such as tumors, infarcts, and encephalopathies are listed as congenital causes of neuromuscular dysfunction of the lower urinary tract in Table 34.1.

Memory Tool:
Think “Brain Drain” to remember that brain conditions can affect urinary function.

Specific Reference Citation:
Table 34.1

Rationale for the Question:
Brain conditions affecting the lower urinary tract can sometimes be overlooked. This question ensures understanding of that relationship.

Question 19

Clinical Vignette:
A 35-year-old male comes in complaining of sudden urinary retention. His medical history reveals a recent car accident where he sustained a spinal cord injury.

Multiple-Choice Options:
A. Transverse myelitis
B. Anorectal malformations
C. Sacral agenesis
D. Extensive pelvic surgery

Answer 19

Correct Answer:
A. Transverse myelitis

Explanation:
Transverse myelitis is an acquired insult to the spinal cord that can lead to neuromuscular dysfunction of the lower urinary tract, as per Table 34.1. Anorectal malformations and Sacral agenesis are congenital causes, while extensive pelvic surgery is another acquired cause but not related to the spinal cord.

Memory Tool:
“Trauma Transforms Tracts” - remember that spinal cord trauma like transverse myelitis can affect urinary function.

Specific Reference Citation:
Table 34.1

Rationale for the Question:
The question underlines the importance of recognizing spinal cord insults like transverse myelitis as causes for urinary dysfunction, especially in trauma cases.

Question 20

Clinical Vignette:
A 10-year-old child is brought in with chronic urinary incontinence. Past medical history reveals a diagnosis of cerebral palsy.

Multiple-Choice Options:
A. Cerebral palsy
B. Occult forms of neural tube defect
C. Conditions of the brain (tumors, infarcts, encephalopathies)
D. Spinal cord insults (Trauma)

Answer 20

Correct Answer:
A. Cerebral palsy

Explanation:
Cerebral palsy is an example of a central nervous system insult that can lead to neuromuscular dysfunction of the lower urinary tract, according to Table 34.1.

Memory Tool:
“CP Sees Pee” - remember that cerebral palsy can cause urinary issues.

Specific Reference Citation:
Table 34.1

Rationale for the Question:
Cerebral palsy as a cause for neuromuscular dysfunction of the lower urinary tract is essential to recognize for better management and treatment options.

Question 21

Clinical Vignette:
A 7-year-old girl is experiencing frequent urinary tract infections and is found to have Lipomeningocele upon investigation.

Multiple-Choice Options:
A. Conditions of the brain (tumors, infarcts, encephalopathies)
B. Occult forms of neural tube defect
C. Extensive pelvic surgery
D. Anorectal malformations

Answer 21

Correct Answer:
B. Occult forms of neural tube defect

Explanation:
Occult forms of neural tube defect like Lipomeningocele can lead to neuromuscular dysfunction of the lower urinary tract. This is listed under congenital causes in Table 34.1.

Memory Tool:
“Occult Options Obstruct” - occult forms of neural tube defects can cause obstructions and UTIs.

Specific Reference Citation:
Table 34.1

Rationale for the Question:
Given that occult forms like Lipomeningocele are often overlooked, this question emphasizes their role in neuromuscular dysfunction of the lower urinary tract.

Question 22

what transverse myelitis is.

Answer 22

Transverse myelitis is an inflammation of the spinal cord that can result in varying degrees of weakness, sensory alterations, and autonomic dysfunction, including bladder and bowel problems. The inflammation often affects the spinal cord across its horizontal (“transverse”) axis, hence the name. It’s critical to diagnose and treat transverse myelitis early, as it can lead to chronic symptoms and disability.

Question 23

Clinical Vignette:
A newborn is having difficulty passing urine and stool. Upon examination, an anorectal malformation is diagnosed.

Multiple-Choice Options:
A. Anorectal malformations
B. Transverse myelitis
C. Conditions of the brain (tumors, infarcts, encephalopathies)
D. Extensive pelvic surgery

Answer 23

Correct Answer:
A. Anorectal malformations

Explanation:
Anorectal malformations are congenital causes of neuromuscular dysfunction of the lower urinary tract, as outlined in Table 34.1.

Memory Tool:
“Ano-Rectal, Ano-Right” - Anorectal issues from birth mean the anatomy isn’t ‘right.’

Specific Reference Citation:
Table 34.1

Rationale for the Question:
It’s vital to recognize anorectal malformations as a potential congenital cause for urinary issues, especially in neonates and infants.

Question 24

Clinical Vignette: You’re consulted for a 9-year-old child with spina bifida who has been experiencing inadequate bladder emptying. On further evaluation, it’s confirmed that the child has inadequate bladder contractions.

Multiple-Choice Options
A) Antimuscarinic therapy
B) CIC
C) Augmentation cystoplasty
D) Urinary diversion

Answer 24

Correct Answer: B) CIC

Explanation: Clean Intermittent Catheterization (CIC) is a minimally invasive treatment option specifically recommended for cases of inadequate bladder contractions. It aims to manually empty the bladder at regular intervals to prevent stasis and infection.

Memory Tool: “CIC is Classic for Contractions” can help you remember that CIC is the treatment of choice for inadequate bladder contractions.

Specific Reference Citation: TABLE 34.2

Rationale for Question: This question is aimed at testing your knowledge of the appropriate minimally invasive intervention for inadequate bladder contractions in a pediatric neurogenic bladder dysfunction case.

Question 25

Clinical Vignette: A 12-year-old boy with cerebral palsy is having issues with emptying his bladder. On urodynamic studies, detrusor sphincter dyssynergia is diagnosed.

Multiple-Choice Options
A) CIC
B) Neuromodulation
C) Augmentation cystoplasty
D) All of the above

Answer 25

Correct Answer: D) All of the above

Explanation: All the options, CIC, Neuromodulation, and Augmentation cystoplasty, are treatments for detrusor sphincter dyssynergia. While CIC and neuromodulation are minimally invasive options, augmentation cystoplasty falls under more invasive treatment options.

Memory Tool: “DSD - Don’t Skip Details” to remind you to consider all treatment options for Detrusor Sphincter Dyssynergia.

Specific Reference Citation: TABLE 34.2

Rationale for Question: The question tests your understanding of the variety of treatment options available for detrusor sphincter dyssynergia, including both minimally invasive and more invasive options.

Question 26

Clinical Vignette: A parent of a 7-year-old with neurogenic bladder dysfunction inquires about overnight treatment options for her child who has inadequate bladder contractions.

Multiple-Choice Options
A) CIC
B) Antimuscarinic therapy
C) Overnight catheter drainage
D) Neuromodulation

Answer 26

Correct Answer: C) Overnight catheter drainage

Explanation: According to TABLE 34.2, overnight catheter drainage is a minimally invasive option specifically mentioned for both inadequate bladder contractions and detrusor sphincter dyssynergia as a treatment option.

Memory Tool: “Night-Over-Catch Drain” helps you remember Overnight catheter drainage as an option for night-time care.

Specific Reference Citation: TABLE 34.2

Rationale for Question: This question addresses the less frequently discussed aspect of nocturnal management of bladder dysfunction, thus filling a potential knowledge gap.