Dkumar+1986 Ultrasonography in Radio Logic 1 58

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1986;78;58-64Pediatrics

Uri Alon, Menucha Pery, Giora Davidai and Moshe BerantInfection

Ultrasonography in the Radiologic Evaluation of Children With Urinary Tract

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Online ISSN: 1098-4275.Copyright © 1986 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.

American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by thePEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it

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58 PED IATR ICS Vo l. 78 N o . 1 Ju ly 1986

U ltrasonography in the R ad io log ic E va lua tion o f

C h ild ren W ith U rin a ry T rac t In fec tion

Un A lon , MD , M enu cha Pery , MD , G io ra D av ida i, M D , and

M osh e Be ran t, M D

F rom the Section o f P ed ia tric N eph ro logy and the Depa rtm en ts o f D iagnos tic R ad io logy

and Ped ia tr ic s , R am ban M ed ica l C en te r, and F acu lty o f M ed ic ine , T echn ion - ls rae l

In s titu te o f T echno logy , H a ifa , Is rae l

ABSTRACT . A prospec tive b lin d s tudy com paring th e

f in d ings o f u ltraso nograph y , in trav en ous p ye lo graphy ,

an d vo id in g cy stou re th rog raphy w as conduc ted o n 81

pa tien ts to exam ine the p lace o f u ltrasono grap hy in th ein itia l rad io lo g ic eva lua tion o f ch ild ren w ith u rina ry tract

in fec tion . Th e p atien ts’ m ean age w as 4 .8 y ea rs; 15 w ere

m ale . F o rty -e igh t w ere in pa tien ts (m ean ag e, 3 .2 yea rs )

and 33 w e re ou tpa tien ts (m ean ag e,.2 years ). In 2 9

p atien ts (35 .8% ) ab no rm a lity o f th e u rin ary sys tem w as

d etec ted b y one o r m o re o f th e th ree im ag in g p rocedu re s ;

21 w ere inpa tien ts and eigh t w ere o u tpa tien ts . T he m o st

freq uen t find ing w as ve sico u re te ra l reflu x , o ccu rrin g in

62 . 1 % of the p atho log ic cases . T he fin d ings at u ltraso -

nog rap hy co rre la ted w e ll w ith tho se o f in trav en ou s pye -

lo g raph y in 7 3 o f th e 8 1 s tud ie s (90 .1% ), b u t they failed

to dem onstra te dou b le co llecting system s and severa l o f

th e m in or ch an ges. H ow ever, u ltraso nograp hy in com bi-

na tion w ith cys tou re th ro g rap hy id en tified all pa tien ts

w ho had ab norm a l u rina ry sy stem s, excep t fo r tw o ch il-

d ren w ith n eg lig ib le f ind ings. M oreo ve r, u ltra sono grap hy

an d cys to u reth ro g rap hy tog eth er iden tif ied a ll 1 1 pa -

tien ts, n ine of them inp atien ts, in w hom surg ica l trea t-

m ent w as ind ica ted . It is conc lud ed th at u ltraso no graph y

can su ccessfu lly rep lace in travenou s p ye log raphy as a

sc reen ing im ag ing procedu re fo r the u rina ry sy stem , bu t

because o f the su pe rio rity o f in traveno us py elo g rap hy in

the de tectio n of som e typ es o f le sion s, in trav enou s pye -

log raphy w ill b e req u ired w h en ev er u ltra so nog raph y or

cysto u reth ro g raph y re su lts a re abno rm al. A cco rd in g ly ,

and in v iew of the d iffe ren ces in th e freq uency and

sev erity o f pa tho log ic find ing s be tw een ou tpa tien ts and

ho sp ita lized p atien ts , th e fo llow in g pro toco l is sug gested

fo r the rad io log ic eva lu atio n of ch ild ren w ith u rina ry

tract in fec tion : F or ou tpa tien ts , cy stou re th rog raphy can

b e p e rfo rm ed 4 to 6 w eek s a fter ce ssa tion of an tib io ticth erapy . If th e s tudy is no rm a l, u ltra so nog raph y can b e

d one ; if th is is a lso no rm al, no fu rthe r rad io log ic w ork up

is n eeded . O n ly w hen cy s tou reth rog rap hy o r u ltrason og -

rap hy find in gs a re abno rm a l is in trav en ous pye log raph y

Rece ived fo r pu b licatio n Ju ly 25 , 1985 ; accep ted O ct 24 , 19 85 .

R eprin t requ es ts to (U -A .) S ection of P ed ia tr ic N ephro logy ,

D epartm en t o f P ed ia tr ics , R am ban M edica l C en te r, H a ifa5254 ,

Israel.

PED IA TR IC S (ISSN 0031 4005 ). C opyrigh t © 1986 by the

A m erican A cadem y of P ed iatric s .

a lso ind icated . F or hosp ita lized pa tien ts, e sp ec ia lly yo ung

ch ild ren , u ltra son ography can be used as the early screen -

in g procedure , w ith in tw o to fo u r days a fte r the d iag nosis

o f u rin ary trac t in fectio n . If the resu lts a re no rm al, cys -tou reth ro g raphy can fo llow after4 to 6 w eeks; if ab nor-

m a l, cys tou re th ro g rap hy can be pe rfo rm ed a fter ten to 1 4

days . H ere , too , in trav enous pye lograp hy is needed on ly

w hen u ltra son ograp hy an d /o r cys tou re th ro g rap hy re su lts

a re a bnorm al. Ped ia tr ic s 1986 ;78 :58-64 ; u l trasonography ,

radiologic eva lua tion , u rinary trac t in fec tion .

R ou tine rad io log ic ev alua tio n o f ch ild ren w ith

u rina ry tra ct in fe ct ion in clude s in traven ous p ye lo g -

raph y (IV P ) an d vo id ing cy stou re th rog raphy , a im -

ing to de te ct pa tien ts a t risk fo r ren al d am ag e,

nam ely , tho se w ith ob s truc tiv e u ro pa th y o r ve s i-

cou re te ra l re f lux .’3 In recen t years , w ith the in -

c rea sing u tiliz a tion of k id ney u ltra son ography and

th e g row in g ev id en ce o f its u sefu lne ss in ch ild ren ,4 ’5

th e q ue st ion a rose as to its p oss ib le va lue in the

rad io log ic ev a lua tion of ch ild ren w ith u rina ry trac t

in fec tion . A ltho ugh a few uncon tro lled stud ie s hav e

add ressed th is q ue st ion ,3 ’6 it w as s ta ted in a re cen t

ed ito ria l7 tha t “ at th is tim e , how ev er, th ere is in -

su ffic ien t exp erience to re comm end so nograph y a s

a ro u tine p rocedure.” O the rs8 have stre ssed th e

need fo r a p rosp ectiv e study eva lu atin g the use fu l-

ness an d reliab ility o f u ltra son ography as a d iag -

no stic too l in ch ild ren w ith u rin a ry trac t in fe c tion .

T he p resen t stud y w as u nde rtak en fo r b ette r c lan -

fica tion o f th e p lace o f u ltrasono grap hy in the

rad io log ic w orku p of ch ild ren w ith u rina ry tract

in fec tion , by com pariso n of the fin d ing s o f IV P ,

v o id in g cy stou ne th rog raphy , and u ltra son ography

in a p ro spective b lin d s tud y o f 81 p atien ts .

MATER IA LS AND METHODS

A ll ch ild ren hosp italized or seen at the o u tpa tien t

clin ic b etw een Jun e 1 , 19 84 , an d A pril 15 , 19 85 ,









a

a?

8a

R ena l u ltraso no graphy an d IV P co rre la ted w e ll

in 7 3 of the 81 p a tien ts (90 .1%), in clud ing a ll o f the

pa tien ts w ith no rm a l k idn ey s and th ose w ith h y -

d ro neph ros is and co n tra c ted k id neys (T ab le 3 ).

O n e -b y -o ne ana lys is o f the e igh t p atien ts in w hom

th ere w as d iscrepancy be tw een the tw o d iagn os tic

m odes in d ic a tes the fo llow ing (T ab les 1 and 2 ): In

pa tien ts 2 , 1 4 , an d 21 u ltra so no graph y fa iled to

de te ct fin d in gs tha t w ere no ted on IV P ; in a ll th re eca ses vo id ing cys tou reth ro g raph y w as abnorm al. In

pa tien ts 18 and 24 a doub le co lle c ting sy s tem w as

no t de tec ted b y u ltra son og rap hy . H ow ev er, in b o th

pa tien ts u ltraso no graph y de te c ted the accom pany -

ing h ydro neph ros is , w h ich w as a lso show n by IV P .

A un ila te ra l do ub le co lle c ting sy stem w itho u t ob -

struc tion o r reflux in p atien t 7 and a ca lyceal cy st

in p atien t 8 w ere d iagno sed on ly by IV P , w hereas

in pa tien t 1 1 o n ly u ltra son og rap hy d isc lo sed th e

cy s tic n atu re o f th e k id ney no t v isua liz ed o n IV P .

T hu s , excep t fo r p atien ts 7 and 8 , v o id ing cy sto -

u re th ro g raph y and u ltra son og rap hy in com b ina tio n

co u ld id en tify a ll ch ild ren w ith an ab no rm a l u rina ry

sy s t em .

E lev en pa tien ts , tw o of w hom w ere o u tp atien ts ,

un de rw en t su rg ic al trea tm en t (T ab le 3 ). F ive o f

them needed imm ed ia te in te rven tion ; a ll w ere in -

pa tien ts and young er th an 15 m on th s . W ith ou t

ex cep tion , u ltra son og rap hy com b ined w ith vo id in g

cy s tou reth rog rap hy d isc lo sed u rin ary sy stem pa -

thology in a ll 1 1 ope ra ted ch ild ren , an d u ltrason og -

r a phy w as gro ss ly abn orm al in all f iv e ch ild ren in

w hom urg en t su rg ic a l tre a tm en t w as in d ic ated .

DISCUSS ION

In traven ous p ye log rap hy ha s b ecom e es tab lish ed

as an im portan t too l in the in vestiga tion o f p atien ts

w ith u rin ary tra ct in fec tio n , bu t its d raw back s in -

dude inv as iv ene ss , rad ia tion exp osu re , a lle rg ic re-

a c tion s , an d rad io co n tra s t-in du ced acu te rena l fa il-

u re .’5 ’16 O n the o th er h an d , u l traso nog raphy o f the

k id neys d oe s no t ca rry such h aza rd s and h as th e

ad van tage s o f b ein g re la t ive ly low e r in co s t, e as ie r

to pe rfo rm , an d ab le to be rep ea ted a s m any tim es

as n eeded an d to en ab le sim ultaneous d em on stra -

t ion o f o the r ab dom in al o rgans . In add ition , te ch -

n ica l adequ acy doe s no t d epend on k id ney fu nc -

t ion .4 ’5”7”8 H ow eve r, rena l u l traso no graph y m ay be

in ferio r to IV P in im ag in g som e de ta ils , su ch a s

u rete rs an d sm a ll sc ars , an d dem and s an exp eri-

enced rad io log ist fo r adequ ate in te rp re ta t ion .2 ’3 ’6

Therefore , it ap pears to b e o f c lin ic al im po rtance

to asse ss w h ethe r and to w ha t ex ten t u ltra son og -

rap hy can rep la ce th e c la ssic ro le o f IV P in the

rou tin e rad io lo g ic eva lu ation o f ch ild ren w ith u n -

na ry tra c t in fe ction .

In th e p re sen t s tud y w e fo und tha t u ltra son og -

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A RT IC L ES 61






. rap hy can e ffec tiv ely rep la ce IV P as a scre en in g> -

a. - C - © C’ ) c : .

a im ag ing p ro cedu re o f th e up pe r u rina ry trac t. U !- #{176} - Ca C ’) ‘-4 c ‘4 tra so no graph ic find ing s w e re s im ilar to IV P find -

- F- - -4

0) 4+ ings in 9 0 .1% of 81 cases , inc lud in g a ll p atien ts) 4 + + + w ith no rm a l k idn ey s , h yd ron ep hro sis, an d con -

a 4 - , .0 C” + + + tra c ted k id neys (T ab le 3 ). O f th e rem ain in g eig h ta C - .4- ’. case s, u ltra so un d w as sup e rio r to IV P in on e ch ilda)a + + + + w ith ch ron ic ren a l fa ilu re and m ulticy s tic d isp la s tic‘C

4 C-.

j + - k idn ey , co n firm in g th e find ing s o f K anga rloo e t aL 6

- gi + + + + In the o the r sev en case s, u ltra son og rap hy w as in -a. . a fe rio r to IV P in the de te ction o f the u rina ry trac ta a.5 #{247 }+ + + I + a an om alies , co n firm ing th e sup erio rity o f IV P in the0

a C ’) ‘C

ca d iagno s is o f m in o r ana tom ic d e ta ils.2 ’6 H ow eve r, + aa -

4) + a ex cep t fo r p atien ts 7 and 8 , w hose n eg lig ib le find -C C

a ings d id no t necessita te any ac tive approach ,3”9 ’2#{176 } + + 1 +1 -a

a a u ltraso nog raphy com bin ed w ith v o id ing cy s tou re-a

-a d ,-; th ro g raph y cou ld de tec t a l l o f th e 2 7 p atien ts w itha) Z

4) ci : - clin ic al ly sign ifican t u rin ary trac t anom a lie s. In 11 ,

- a on ly vo id ing cy s tou reth rog rap hy w as ab no rm a l; in

C I + -4 ten , bo th v o id in g cy s tou reth rog rap hy and u ltra so -+

a 4)a

r- + + + + n og rap hy w e re abno rm al; and in the o the r s ix , on lyC. )

u ltra son og rap hy w as ab no rm a l (T ab le 3 ). +

a. - M ason3 an d K ang a rloo e t a l ,6 in the ir re tro sp ec -

: & t ) # {247 } + tiv e s tu d ie s , re ached s im ilar con clus ion s , n am e ly ,. )

E -’ Z + + I tha t u l traso no graph y can rep la ce IV P as a scre en - ++ a-

‘C a in g p ro cedu re . In trav en ou s py elo g raph y is nev er-a S the le ss ind ic ated w h en ev er u ltraso no graph y or

+ ++

-I a? vo id in g cy stou re th rog rap hy a re fo un d to be ab no r-a 4 -,. . m al b ecau se IV P can also re flec t k id ney fu nc tio n: #{247 }++

a o + and m ay beupe rio r in d iag nos in g som e o f thea)

anom alie s an d the fin e d eta ils , su ch as d oub le co l-‘C I 0

a. 8 le c tin g sys tem s an d scars . M aso n3 p rop ose s sta rtin ga I a?;a )H+ ++ ‘C . )a I0 I a

0) I + S -a the n ad io log ic eva lu atio n o f ch ild ren w ith u rin aryaci aa

.8 I + I a trac t in fec tio n w ith vo id in g cy s tou reth rog rap hy ,a w hereas the o the r au tho rs6 recom m end beg in n in go CO + + a a w ith u ltra son og rap hy . A n aly s is o f th eir s tu d ie s

- L f) + show s th a t they add ress , in fac t, tw o d iffe ren t pa -. . I

C.) tien t p opu la tio ns . W he reas M aso n3 exam ined ou t-.8 +

a. pa tien ts w ho w ere refe rred fo r rad io log ic ev alu a- C ’) + + + !- tion , K angarloo e t a !6 rev iew ed da ta derivedmain lya I Ia 2 from in pa tien ts an d com p lic ated ca ses th at w e reC l) a ?5bC ‘C-.

a _ n re fe rred to the ir m ed ical c en te r. In deed , th e fre -+ oa‘8 qu en c ies o f abn orm al rad io lo g ic fin d in gs o f ap p ro x -

.8 - I ‘C. )

C . L 0 im ate ly 23% am ong the o u tp atien ts3 an d 49%C. )

-a a tie n ts in ou r p re sen t se rie s. In ad d ition , a l tho ugh- . 00 ;C. ; ;C.- _, - am ong the inp a tien ts6 a re sim ila r to the re spec tive0 a. bl) fig u re s o f 22 .4% in ou tpa tien ts an d 43 .8% in in pa -C C l)

‘

. a 0 ‘l l 9 M ason do es n o t p ro v ide exac t d e tails , com parison: 8 .,- a; a a? of the tw o a fo rem en tio ned re tro spec tiv e s tud ie s

a a a

8 2 I : ‘ a? a a show s th at th e seve rity o f th e abn orm al find ing sa? 4)

8 a 8 : w as g rea te r am ong the inp atien ts . T h is is a lso truen o ‘Ca?cC) .8 a 0

a? b l)C I) - a -a a C- bl) a a fo r the p re sen t s tu dy , in w h ich n ine o f the 11

a.a a2 a ‘Crn, aa oa

a? a a n p atien ts w ho requ ired su rg ica l trea tm en t, as w e ll asC’ 5 89 a : . a ll f iv e in w hom im m ed iate su rg ica l in te rv en tionIii 1 a a a a w as in d ic a ted , w e re inp atien ts . T he refo re , ou r fin d - ;; 2 0

a 8 <a a?

I- a 0 0 0 C l) .,- ..-‘ ing s com b ined w ith tho se o f the tw o o the r s tu d ie s3 ’6

62 U LTRASONOGRAPHY IN UR INARY TRACT INFECT IONby on September 10, 2010www.pediatrics.orgDownloaded from






NORMAL

NORMA l NORMAL

, -C

ASNORMAL [ VCUGJ . _ : _ 4OUTpAT IENT1

, / WEEK S

“ABNORMAL

v P 1

O THER INVES T IGA T ION S ,

MED ICA L OR SURG ICA L

T R EA TMEN T

F i g u r e . A lgor i thm for ini ti al radiologi c evaluati on of

chi l dren w i th urinary tract i nfecti on. Protocol for i npa-

t ients i s descri bed by sol i d arrow s and protocol f or out-

pati ents by dashed arrow s. A bbrev i ations are: IV P, i ntra-

venous pyelography ; US, renal ul trasonography ; V CUG,

v oi di ng cy st our et hr ogr aphy .

AR T IC LE S 6 3

support B en-A m i ’ s suggesti on2 that outpati ents and

hospi tal i zed chi l dren deserve a di f ferent radiologic

strategy.

Based on the cumulati ve data and recommenda-

t ions f rom the l i terature2’ 3’ 6 and f rom the present

study , w e propose an algori thm f or the radiologi c

evaluation of chi ldren w i th urinary tract inf ection

(Figure). T he investi gati on of outpati ents should

start w i th voiding cystourethrography , w hich candisclose the major i ty of 21 This pro-

cedure should preferably be perf ormed 4 to 6 w eeks

af ter completion of the ini t i al antim i crobial thera-

peuti c course, in order to avoid radiologic f indings

attr i butable to the acti v e inf l ammation.2’ 7 I f v oiding

cystourethrography is normal , the studies proceed

w i th ul trasonography ; i f thi s investi gati on i s al so

normal , no f urther radiologi c w orkup is necessary .

I n the event that voiding cystourethrography is

abnormal , IV P is indicated and ul trasonography is

not necessary . I ntravenous pyelography is al so in-

dicated w hen ul trasonography is f ound to be abnor-

mal.

For hospi tal i zed chi l dren, w ho are usual l y

younger and more severel y i l l , our suggesti on i s in

agreement w i th the recommendations of B en-A mi2

and K angarl oo et al ,6 ie, to start w i th an earl y

ul trasonography as a screening procedure when di -

agnosing those patients w ho requi re immediate sun-

gi cal management. I f ul trasonography is normal ,

voi ding cystourethrography is to be scheduled as in

outpati ents. In case voiding cystourethrography is

al so found to be normal , no f urther radiologi c stud-

ies are requi red. On the other hand, i f voiding

cystounethrography is abnormal , then IV P isdi -

cated. W hen ul trasonography i n the inpati ent i s

abnormal , then voiding cystourethrography and

I V P should be perf ormed much earl i er, once the

acute infecti on has subsided.2

Wi th thi s algor i thm , according to our data and

those of M ason,3 about 75% of the outpati ents w i l l

have to undergo only voi ding cystourethrography

and ul trasonography ; about 20% w i l l need voidingcystourethrography and IV P, and only less than 5%

w i l l have to be exam ined by al l three studies. Thus,

when this scheme is appl ied, three quarters of the

outpati ents w i l l be spared IV P, and less than 5%

w i l l have to be exam ined by al l three imaging pro-

cedures. B y thi s approach, the need f or IV P in

inpati ents w i l l be reduced by more than 50% .

I t shoul d be emphasized that al l current w orks

deal w i th the ini ti al radi ologic evaluation of chi l -

dren w i th ur inary tract infecti on; therefore, not

enough data are avai l able f or comparing IV Ps

ul trasonography in the long-term radiologi c f ol l ow -

up of these patients. W y ly et al ’ #{ 176}ave recentl y

demonstrated the ef f i cacy of ul trasonography i n the

radiologi c investi gati on of compl i cated duplex k id-

neys, and del l ’ A gnola et a117 reported on the usef ul -

ness of ul trasonography in the postoperati v e man-

agement of chi l dren w i th hydronephnosis. I t i s pos-

sible that further experience w i l l prov ide better data

to assess the rel i abi l i ty of ul trasonography as a

substi tute f or JV P in these and other pathologi c

conditions.2’6’8

I n summary, the present prospecti ve bl i nd study

conf i rm s the observati on that ul trasonography can






64 U LTRASONOGRAPHY IN UR INAR Y TR AC T IN F E C T IO N

successf ul l y replace IV P as a screening imaging

procedure in the ini t ial radiologic evaluation of

chi ldren w i th urinary tract inf ection. I n expeni -

enced hands, ul trasonography can obv iate the need

f or IV P in the normal cases, but I V P w ould sti l l be

requi red w henever an abnormal i ty i s detected by

ul trasonography and/or voiding cystourethrogra-

phy . D i f f erent radiologic approaches should be

adopted for inpatients and outpatients. W hereas inhospi tal i zed chi ldren studies should start w i th an

early ul trasonography, the radiol ogic i nvestigation

of outpatients can begin w i th a delayed voiding

cystourethrography. Fi nal l y , i t must be noted that

the def i ni tion ofa chi ld w i th urinary tract i nf ecti on

as “ inpatient” or “ outpatient” does not necessar i l y

have to be rigid. Some outpatients, especial l y the

young ones, m ight be regarded as “ inpatient” and

v ice versa; some hospi tal i zed chi ldren, in parti cular

the older ones, w i th an uneventful course may

fol low the “ outpati ent” protocol , leav ing to good

cl inical judgment the decision as to along which

side of the algori thm the indiv idual patient w i l l be

studied.

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1986;78;58-64Pediatrics

Uri Alon, Menucha Pery, Giora Davidai and Moshe BerantInfection

Ultrasonography in the Radiologic Evaluation of Children With Urinary Tract

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