Pediatric Pyelonephritis Clinical Presentation

  • Author: Robert W Tolan Jr, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Feb 9, 2012
 

History

Signs and symptoms of urinary tract infection (UTI) and pyelonephritis vary with the age of the patient. Neonates often present with nonspecific symptoms of jaundice, hypothermia or fever, poor feeding, vomiting, and failure to thrive. Neonates, especially male newborns, may develop hyponatremia and hyperkalemia as a result of secondary pseudohypoaldosteronism.

Infants and young children aged 2 months to 2 years often present with nonspecific symptoms of fever lasting longer than 48 hours, as well as with poor feeding, vomiting, and diarrhea. Their urine may be malodorous; hematuria may be noted.

Preschoolers and school-age children present with fever for greater than 48 hours. They may complain of abdominal pain or flank pain. Vomiting, diarrhea, and anorexia may be present. Their urine is typically malodorous, and hematuria may be noted. Voiding-related symptoms including enuresis, dysuria, urgency, and frequency, may occur but need not be present.

Adolescents are most likely to present with the classic adult symptoms of fever, often with chills, rigors, and flank pain. They may have abdominal and suprapubic pain, along with voiding-related symptoms of frequency, dysuria, and hesitancy. Their urine is most often malodorous, and hematuria is variably present.

Next

Physical Examination

Because many symptoms of pyelonephritis are nonspecific, complete physical examination is necessary to exclude other causes of the patient's symptoms. Specific findings are as follows.

General appearance

Most infants and children are uncomfortable and appear ill. Older children and adolescents may be mildly to moderately ill.

Vital signs

Fever may be present, with body temperature of more than 38°C, and often more than 39°C. Tachycardia may be present, secondary to fever and pain. Blood pressure is usually normal. Hypertension should raise concern for clinically significant obstruction or renal parenchymal disease. Hypotension may occur if sepsis and shock are present.

Abdominal findings

Abdominal pain may be present. A mass may indicate obstruction, hydronephrosis, or another anatomic abnormality. Suprapubic pain may be present. A palpable bladder indicates obstruction or functional difficulty in starting or completing voiding.

Adolescent girls may have right upper quadrant pain similar to that observed in patients with cholecystitis.

Back findings

Tenderness in the costovertebral angle (CVA), back, or flank is likely to be present in older children and adolescents. Sacral dimple or birthmarks overlying the spine may be associated with an underlying anomaly of the spinal cord. Vertebral abnormalities may be evident.

Genitourinary findings

Assess for irritation, pinworms, vaginitis, trauma, or signs of sexual abuse. A bulging hymen suggests an imperforate hymen and urethral obstruction.

Neurologic findings

Weak lower extremities or diminished reflexes may be signs of spinal-cord dysfunction, and they may be associated with a neurogenic bladder.

Previous
Proceed to Differential Diagnoses
 
 
Contributor Information and Disclosures
Author

Robert W Tolan Jr, MD  Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine

Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility

Disclosure: Novartis Honoraria Speaking and teaching

Coauthor(s)

Stephen C Aronoff, MD  Waldo E Nelson Chair and Professor, Department of Pediatrics, Temple University School of Medicine

Stephen C Aronoff, MD is a member of the following medical societies: Pediatric Infectious Diseases Society and Society for Pediatric Research

Disclosure: Nothing to disclose.

Andrea CS McCoy, MD  Associate Professor of Pediatrics, Temple University School of Medicine; Chief Medical Officer, Jeanes Hospital

Andrea CS McCoy, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Leslie L Barton, MD Professor Emerita of Pediatrics, University of Arizona College of Medicine

Leslie L Barton, MD is a member of the following medical societies: American Academy of Pediatrics, Association of Pediatric Program Directors, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

References

  1. Montini G, Tullus K, Hewitt I. Febrile urinary tract infections in children. N Engl J Med. Jul 21 2011;365(3):239-50. [Medline].

  2. Shaikh N, Ewing AL, Bhatnagar S, Hoberman A. Risk of renal scarring in children with a first urinary tract infection: a systematic review. Pediatrics. Dec 2010;126(6):1084-91. [Medline].

  3. Lundstedt AC, Leijonhufvud I, Ragnarsdottir B, et al. Inherited susceptibility to acute pyelonephritis: a family study of urinary tract infection. J Infect Dis. Apr 15 2007;195(8):1227-34. [Medline].

  4. Faust WC, Diaz M, Pohl HG. Incidence of post-pyelonephritic renal scarring: a meta-analysis of the dimercapto-succinic acid literature. J Urol. Jan 2009;181(1):290-7; discussion 297-8. [Medline].

  5. Bhat RG, Katy TA, Place FC. Pediatric urinary tract infections. Emerg Med Clin North Am. Aug 2011;29(3):637-53. [Medline].

  6. Williams GJ, Macaskill P, Chan SF, Turner RM, Hodson E, Craig JC. Absolute and relative accuracy of rapid urine tests for urinary tract infection in children: a meta-analysis. Lancet Infect Dis. Apr 2010;10(4):240-50. [Medline].

  7. Pecile P, Romanello C. Procalcitonin and pyelonephritis in children. Curr Opin Infect Dis. Feb 2007;20(1):83-7. [Medline].

  8. American Academy of Pediatrics. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. Aug 28 2011;[Medline].

  9. Wang YT, Chiu NT, Chen MJ, et al. Correlation of renal ultrasonographic findings with inflammatory volume from dimercaptosuccinic acid renal scans in children with acute pyelonephritis. J Urol. Jan 2005;173(1):190-4; discussion 194. [Medline].

  10. [Guideline] Subcommittee on Urinary Tract Infection; Steering Committe on Quality Improvement and Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. Aug 28 2011;[Medline].

  11. Lee YJ, Lee JH, Park YS. Risk Factors for Renal Scar Formation in Infants With First Episode of Acute Pyelonephritis: A Prospective Clinical Study. J Urol. Jan 18 2012;[Medline].

  12. Kovanlikaya A, Okkay N, Cakmakci H, et al. Comparison of MRI and renal cortical scintigraphy findings in childhood acute pyelonephritis: preliminary experience. Eur J Radiol. Jan 2004;49(1):76-80. [Medline].

  13. Kavanagh EC, Ryan S, Awan A, et al. Can MRI replace DMSA in the detection of renal parenchymal defects in children with urinary tract infections?. Pediatr Radiol. Mar 2005;35(3):275-81. [Medline].

  14. Montini G, Rigon L, Zucchetta P, et al. Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial. Pediatrics. Nov 2008;122(5):1064-71. [Medline].

  15. Hodson EM, Willis NS, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. Oct 17 2007;CD003772. [Medline].

  16. Williams GJ, Wei L, Lee A, Craig JC. Long-term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database Syst Rev. Jul 19 2006;3:CD001534. [Medline].

  17. Garin EH, Olavarria F, Garcia Nieto V, et al. Clinical significance of primary vesicoureteral reflux and urinary antibiotic prophylaxis after acute pyelonephritis: a multicenter, randomized, controlled study. Pediatrics. Mar 2006;117(3):626-32. [Medline].

  18. Bloomfield P, Hodson EM, Craig JC. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. Jan 25 2005;CD003772. [Medline].

  19. Huang YY, Chen MJ, Chiu NT, Chou HH, Lin KY, Chiou YY. Adjunctive Oral Methylprednisolone in Pediatric Acute Pyelonephritis Alleviates Renal Scarring. Pediatrics. Aug 15 2011;[Medline].

 
Previous
Next
 
Application of low-risk criteria and approach for the febrile infant: A reasonable approach for treating febrile infants younger than 3 months who have a temperature of greater than 38°C.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2012 by WebMD LLC.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.